THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 
DR.  ROY  VAN  WART 


THE  TREATMENT  AND 

CARE  OF  THE  INSANE 

IN  PENNSYLVANIA 


BY 

C.  FLOYD /HAVILAND,  M.D. 


PUBLISHED  BY 

THE  PUBLIC  CHARITIES  ASSOCIATION 

OF  PENNSYLVANIA 

EMPIRE  BUILDING,  PHILADELPHIA 

1915 


PUBLICATION  No.  15 


THE  TREATMENT  AND 

CARE    OF   THE   INSANE 

IN  PENNSYLVANIA 


BEING 

THE  REPORT  OF  A  SURVEY  OF  ALL  THE 

INSTITUTIONS  IN  PENNSYLVANIA  CARING 

FOR  THE  INSANE 


MADE  FOR 

THE  PUBLIC  CHARITIES  ASSOCIATION 
OF  PENNSYLVANIA 

BY 
C.  FLOYD  HAVILAND,  M.D. 


DURING 

THE  SIX  MONTHS  FROM 

JUNE  1  TO  DECEMBER  1 

1914 


PUBLICATION  No.  IS 


PUBLISHED  BY 

THE  PUBLIC  CHARITIES  ASSOCIATION 

OF  PENNSYLVANIA 

EMPIRE  BUILDING,  PHILADELPHIA 

1915 


fliomedieaJ 
Library 


\\x\t 


Table  of  Contents 


INTRODUCTION,  BY  CHARLES  H.  FRAZIER,  M.D  ........................  4 

RESOLUTION  ADOPTED  BY  PENNSYLVANIA  STATE  BOARD  OF  CHARITIES  IN 

1870  ...........................................................  6 

t,  AUTHOR'S  INTRODUCTORY  STATEMENT  ................................  7 

w  MUNICIPAL  INSTITUTIONS  FOR  THE  INSANE  ...........................  14 

«-  SUMMARY  OF  MUNICIPAL  INSTITUTIONS  ...............................  20 

I  LICENSED  COUNTY  INSTITUTIONS  FOR  THE  INSANE  .....................  22 

GENERAL  CONSIDERATIONS  OF  LICENSED  COUNTY  INSTITUTIONS  .........  68 

UNLICENSED  ALMSHOUSES  CARING  FOR  THE  INSANE  ....................  69 

SUMMARY  OF  UNLICENSED  ALMSHOUSES  ..............................  80 

v  GENERAL  SUMMARY  ...............................................  81 

Relative  Merits  of  State  and  County  Care  .....................  82 


635345 


Introduction 

THERE  are  more  than  eighteen  thousand  indigent  insane  in 
Pennsylvania.  Less  than  eleven  thousand  of  these  unfortunates 
are  cared  for  in  State  Hospitals.  Yet  these  State  Hospitals 
"afford  practically  the  only  opportunity  in  the  State  of  Pennsyl- 
vania for  a  public  mental  case  to  receive  active  medical  treatment 
directed  to  the  alleviation  or  cure  of  mental  disease." 

In  so  many  of  the  local  hospitals  and  almshouses  the  insane 
are  accorded  precisely  the  opposite  of  the  remedial  treatment 
which  they  should  receive.  Instead  of  care  they  are  neglected. 
Instead  of  wholesome  and  varied  food  they  receive  ill  prepared 
and  unfit  diet,  and  often  very  scanty  at  that.  Instead  of  the  full 
view  of  the  sky  they  have  the  board  fence,  or  worse,  surrounding 
the  Exercise  Yard.  Instead  of  freedom  they  have  the  hand-cuff 
or  the  strait-jacket.  No  class  of  persons,  sick  or  well,  more 
need  regulated  occupation  and  exercise  and  open  air  work,  such 
as  farm  work  and  plenty  of  room,  than  the  insane. 

They  need  all  that  well  people  need  to  keep  them  well,  plus  the 
best  medical  care  and  treatment.  Locked  up,  out  of  sight,  neg- 
lected, forgotten,  their  misery  cannot  be  told.  The  strongest  in 
physical  health  and  mental  vigor  would  break  down  if  subjected 
to  the  treatment  which  several  thousand  of  our  insane  fellows  in 
the  State  of  Pennsylvania  continue  to  suffer  needlessly. 

As  long  ago  as  1870  the  late  Mr.  George  L.  Harrison,  then 
President  of  the  State  Board  of  Charities,  advocated  the  "estab- 
lishment by  the  State,  within  a  reasonable  time,  of  sufficient 
accommodation  for  the  maintenance  and  treatment  of  all  the 
insane  who  may  not  be  cared  for  in  private  hospitals." 

Forty-four  years  later  Mr.  Harrison's  son,  Mr.  Charles  Custis 
Harrison,  by  his  generosity  made  it  possible  for  The  Public  Chari- 
ties Association  of  Pennsylvania  to  employ  Dr.  C.  Floyd  Havi- 
land,  of  the  Kings  Park  State  Hospital,  Kings  Park,  Long  Island, 

Ul 


New  York,  to  make  a  six  months'  study  of  all  the  institutions  in 
Pennsylvania  caring  for  the  insane. 

The  following  pages  contain  a  summarized  report  of  Dr. 
Haviland's  survey. 

This  report  demonstrates  beyond  peradventure  that  to-day, 
as  in  1870,  the  most  advanced  step  possible  on  behalf  of  the  in- 
digent insane  in  Pennsylvania  is  the  adoption  of  a  plan  by  which 
the  State  shall  support  and  care  for  all  its  dependent  insane  in 
institutions  owned  and  controlled  by  it.  Anything  short  of  this 
is  a  mere  make-shift. 

Is  not  a  period  of  forty  and  more  years  a  long  enough  time  for 
discussion?  If  so,  has  not  the  time  now  come  for  action? 

CHARLES  H.  FRAZIER,  M.D., 

President 
The  Public  Charities  Association 

of  Pennsylvania. 
April  p,  1915. 


[51 


Resolution  Adopted 
by 

Pennsylvania  State  Board  of 
Public  Charities  in  1870 


HON.  GEORGE  L.  HARRISON,  President 


Resolved,  That  the  Board  of  Public  Charities,  having 
witnessed  the  evils  which  result  from  connection  of 
insane  asylums  with  almshouses,  and  believing  that  a 
wrong  is  done  to  the  insane  by  classing  them  with 
paupers,  hindering  the  public  from  estimating  aright 
their  claims  to  sympathy  and  remedial  treatment,  dis- 
approve of  such  an  alliance,  and  believe  that  the  best 
interest  of  this  afflicted  class  of  people  and  the  duty 
of  the  State  concur  in  the  establishment  by  the  State, 
within  a  reasonable  time,  of  sufficient  accommodation 
for  the  maintenance  and  treatment  of  all  the  insane 
who  may  not  be  cared  for  in  private  hospitals. 

Resolved,  That,  in  the  judgment  of  the  Board,  all  super- 
intendents of  hospitals  for  the  insane  should  be  mem- 
bers of  the  medical  profession. 


THE   TREATMENT   AND    CARE  OF  THE    IN- 
SANE IN  PENNSYLVANIA 

BEING  THE  REPORT  OF  A  SURVEY  OF  ALL  THE  INSTITU- 
TIONS IN  PENNSYLVANIA  CARING  FOR  THE  INSANE, 
MADE  TO  THE  MEMBERS  OF  THE  COMMITTEE  ON  MEN- 
TAL HYGIENE,  OF  THE  PUBLIC  CHARITIES  ASSOCIATION 
OF  PENNSYLVANIA 

GENTLEMEN:  In  accordance  with  the  plan  outlined  by 
you,  and  with  the  sanction  of  the  Committee  on  Lunacy 
of  the  Pennsylvania  State  Board  of  Public  Charities,  I  have  com- 
pleted a  survey  of  the  State,  as  regards  the  conditions  attending 
the  care  of  the  insane  and  defectives,  so  far  as  they  are  confined 
in  public  institutions. 

It  is  unfortunate  that  there  is  little  opportunity  for  the  public 
to  learn  about  such  conditions  and  hence  public  interest  is  apt 
to  be  limited.  The  importance,  however,  of  properly  dealing 
with  the  insane  can  scarcely  be  overestimated.  The  modern 
conception  of  mental  disease,  as  a  condition  resulting  in  defective 
social  adjustment,  renders  it  easier  to  understand  the  intimate 
relationship  existing  between  abnormal  mental  states  and  such 
social  evils  as  vagrancy,  intemperance,  immorality,  crime,  etc. 
Such  relationship  is  now  indisputable,  and  it  reveals  the  necessity 
of  adequately  dealing  with  the  problem  of  the  insane,  not  as  an 
academic  question  but  as  a  practical  issue  involving  numerous 
social  ills  directly  and  indirectly  dependent  upon  mental  dis- 
orders. To  successfully  combat  such  ills  mental  disease  itself 
must  be  first  successfully  combated.  It  is  far  more  than  a  ques- 
tion of  mere  custodial  care  for  the  insane ;  what  is  needed  is  that 
every  known  means  be  provided  for  the  treatment  and  especially 
for  the  prevention  of  insanity. 

Mental  disease  not  only  vitally  affects  society  as  a  whole  but 
either  directly  or  indirectly  it  affects  every  individual  member  of 

[71 


the  community.  The  proper  care  and  treatment  of  even  the 
dependent  insane  should,  therefore,  be  regarded  as  a  community 
investment,  a  matter  of  self-preservation  rather  than  as  a  charity. 
The  monetary  cost  of  the  social  evils  which  depend  in  a  large 
measure  upon  mental  disease  is  far  greater  than  the  cost  of 
adequately  treating  insanity  and  thus  to  a  great  extent  removing 
one  of  the  fundamental  causes  of  such  evils.  In  so  far  as  insane 
patients  fail  of  recovery,  through  a  lack  of  proper  care  and  treat- 
ment, just  so  far  does  such  lack  mean  unnecessary  economic  loss. 
Charity  implies  giving  without  thought  of  return,  but  proper 
facilities  for  the  insane  imply  large  returns  not  only  in  human 
happiness  but  in  economic  advantage  and,  therefore,  an  insane 
patient  receiving  treatment  in  a  public  institution  should  be  con- 
sidered no  more  a  recipient  of  charity  than  is  the  farmer  hauling 
his  produce  to  market  over  a  State  road.  In  each  instance  the 
individual  receives  a  direct  benefit  from  a  public  utility,  but 
society's  gain  is  no  less  real  because  indirect.  Proper  treatment 
of  the  insane  is  merely  a  form  of  social  insurance. 

No  system  of  care  for  the  insane  can  be  permanently  successful 
without  a  sustaining  public  opinion,  and  no  method  of  moulding 
public  opinion  is  equal  to  the  presentation  of  facts;  hence  in 
making  the  survey  every  effort  was  made  to  insure  such  a  state- 
ment as  would  bear  internal  evidence  of  an  impartial,  unpreju- 
diced attitude  in  collecting  data  and  of  the  truth  of  every  fact 
stated.  If  any  change  in  existing  conditions  is  needed  facts 
alone  should  be  used  to  determine  the  direction  of  such  change. 

With  the  kindly  assistance  of  Mr.  Bromley  Wharton,  General 
Agent  and  Secretary  of  the  State  Board  of  Public  Charities,  and 
Dr.  Frank  Woodbury,  Secretary  of  the  Committee  on  Lunacy, 
of  such  Board,  a  list  was  prepared  of  all  public  institutions  in 
the  State  known  to  care  for  the  insane,  classifying  them  as  to 
type;  it  was  thus  shown  there  are  8  State  hospitals,  19  County,  or 
Poor  District,  hospitals,  and  4  Municipal  hospitals,  while  in  n 
almshouses  insane  persons  are  kept  for  a  greater  or  lesser  period, 
3  of  the  almshouses  maintaining  distinct  insane  departments, 
although  unlicensed  to  do  so.  With  such  widely  varying  types 
of  institutions  a  brief  sketch  of  the  manner  in  which  the  care  of 
the  insane  has  developed  in  Pennsylvania  may  serve  to  render 
more  intelligible  the  present  situation. 

Originally  the  insane  who  had  become  dependent,  by  reason  of 

[8] 


their  infirmity  or  otherwise,  were  cared  for  by  poor  districts  in 
the  almshouses,  together  with  all  other  dependent  persons,  sick 
or  well,  thus  following  the  early  English  custom.  The  concep- 
tion of  insanity  as  a  sickness  had  not  then  become  prevalent  and 
it  was  not  until  the  notable  memorial  was  presented  to  the  State 
Assembly  in  1845,  by  Dorothea  Dix,  that  the  community  awoke 
to  a  realization  of  the  need  for  a  change.  Then  it  was  that  the 
State  first  took  official  action  regarding  the  insane,  who  were 
described,  in  the  memorial  mentioned,  as  being  housed  in  build- 
ings unfit  for  human  habitation  and  receiving  not  only  no  medical 
attention  but  only  custodial  care  of  the  crudest  sort.  In  an  effort 
to  correct  conditions  laws  were  passed  in  1845  and  in  1848,  pro- 
viding for  the  first  State  institution  for  the  "Care  of  the  Insane 
of  this  Commonwealth,"  which  was  then  known  as  the  Pennsyl- 
vania State  Lunatic  Asylum,  at  Harrisburg.  The  counties  were 
granted  the  right  to  send  a  proportionate  number  of  their  insane 
to  it,  remaining  responsible,  however,  for  such  patients'  main- 
tenance,— the  State  providing  only  the  material  plant.  After 
some  years,  a  single  institution  proved  inadequate,  and  there 
followed  the  establishment,  in  1853,  of  the  semi-public  institu- 
tion known  as  Dixmont,  located  near  Pittsburgh.  Within  a 
few  years  such  provisions  were  found  insufficient  and  there  was 
established  a  State  institution  for  the  insane,  in  1868,  at  Dan- 
ville, but,  even  with  such  added  accommodations,  a  large  num- 
ber of  the  insane  still  remained  in  almshouses,  and  we  find  in  the 
annual  report  of  the  State  Board  of  Public  Charities  for  1870 
reference  to  the  matter  as  follows : 

"More  especially  do  we  wish  to  denounce  the  cruel  wrongs 
which  the  insane  suffer  who  are  inmates  of  almshouses;  these 
institutions  are  generally  wholly  unsuited  for  their  care  or  even 
detention,  or,  if  suitable,  are  presided  over  by  persons  who  are 
entirely  ignorant  of  the  needs  of  this  class  of  the  sick  or  infirm, 
and  whose  administration  is  based  on  the  crudest  ideas  of  mental 
diseases.  *  *  *  No  hospital  for  the  insane  should  remain 
without  the  constant  supervision  of  a  medical  superintendent. 
The  stewards  of  almshouses  are  never  selected  from  any  con- 
sideration of  the  needs  of  the  insane." 


Accompanying  the  report  above  quoted  was  a  copy  of  the  reso- 
lutions which  follow  the  title-page  of  this  report. 


In  1871,  the  General  Agent  of  the  Board  of  Public  Charities 
reported,  with  regard  to  the  insane  in  almshouses,  as  follows: 

"Indeed,  without  a  total  revolution  of  the  system,  it  is  impos- 
sible to  greatly  improve  it.  There  may  be  great  faults  in  the 
management  of  these  poorhouses,  some  of  which  might  be  reme- 
died, and  others  are  probably  incapable  of  remedy,  but  the  great 
cause,  the  fundamental  cause  of  the  evil,  is  the  system  itself.  If 
the  administration  was  made  as  perfect  as  human  infirmities 
allow,  if  the  best  superintendents  or  wardens,  and  the  most  faith- 
ful attendants  were  secured,  while  the  evil  might  be  mitigated,  it 
would  remain  substantially  the  same  until  the  system  itself  is 
changed.  The  remedy  is  not  reform,  but  revolution." 

Again,  the  following  year,  in  1872,  Hon.  George  L.  Harrison, 
President  of  the  Board  of  Public  Charities,  reported  to  the 
Assembly,  in  reference  to  the  same  subject,  as  follows: 

"For,  at  the  best,  they  are  merely  confined  in  places  of  deten- 
tion, under  the  guardianship  of  a  respectable  overseer,  who  is 
wholly  ignorant  of  their  disease  and  of  the  means  necessary  for  its 
alleviation  or  its  cure.  We  say  at  the  best:  we  hesitate  to  de- 
scribe the  reverse  of  the  picture;  it  would  exhibit  a  scene  of  as 
cheerless  and  uncomforted  misery  as  the  most  bitter  misanthrope 
could  desire  to  look  upon.  *  *  *  The  victims  in  this  case 
are  a  class  of  defenseless  invalids,  whose  circumstances  appeal 
with  a  special  urgency  to  every  sense  of  humanity  and  justice. 
Houses  of  detention,  simply  as  such,  misrepresent 
the  real  demand  of  an  enlightened  public  mind  in  relation  to  all 
classes  of  unfortunates, — they  ignore  the  principle  of  the  dignity 
of  the  human  person,  which  should  govern  the  consideration  of 
these  classes.  This  discrimination  is  lost  where  the  thought  pre- 
vails that  the  chief  good  to  be  obtained  is  to  restrain — to  save  the 
public  in  some  sort  from  inconvenience,  or  damage,  or  depreda- 
tion. This  should  surely  be  looked  after  and  secured,  but  its 
complete  attainment  may  be  better  accomplished  by  considering 
at  the  same  time  the  duty  of  humanity  in  the  care  and  custody  of 
every  class  of  defectives.  There  are  noble  examples  and  expo- 
nents of  this  theory  in  this  age,  in  all  parts  of  the  civilized  world, 
and  nowhere  more  devoted  to  its  realization  than  in  our  own  coun- 
try, and  in  our  own  State,  and  we  believe  that  a  very  large  num- 
ber of  the  insane  in  this  Commonwealth  are  not  only  skillfully 
but  tenderly  treated.  But  this  is  not  so  in  many  of  the  county 
poorhouses;  they  have  neither  the  accommodations  nor  the 
medical  care  which  are  suited  to  their  wants.  *  *  *  There 
is  nothing  more  true  than  that  the  State  or  county  must  pay  for 
the  support  of  the  sufferers  during  life,  unless  suitable  provision 

[10] 


for  care  and  treatment  induce  timely  restoration.  It  is  therefore 
no  more  than  the  common  wisdom  that  is  applied  to  the  ordinary 
business  of  life  to  take  such  measures  as  will  give  them  the  best 
opportunity  of  restoration  that  the  age  affords." 

It  is  remarkable  that  the  enlightened  words  above  quoted 
should  have  been  written  over  forty  years  ago,  when,  as  this  re- 
port will  show,  they  are  as  applicable  to-day,  so  far  as  almshouse 
care  of  the  insane  is  concerned,  as  they  were  when  written. 

Largely  due  to  the  wisdom  and  effort  of  the  State  Board  of 
Public  Charities,  the  situation  was  still  further  relieved  when 
there  was  established  another  State  institution  for  insane  at 
Warren,  in  1873,  and  still  later  there  was  established  the  State 
Hospital  at  Norristown,  in  1876. 

But  the  number  of  the  insane  always  exceeded  the  accommoda- 
tions provided,  and  when,  in  1883,  a  law  was  passed  whereby  the 
State  took  half  the  burden  of  maintenance  and  made  mandatory 
the  removal  of  all  insane  to  the  State  hospitals,  overcrowding 
resulted  from  the  first.  With  the  passing  years,  it  finally  became 
a  physical  impossibility  to  house  all  the  insane  in  the  State  hos- 
pitals and,  in  an  effort  to  improve  conditions,  the  County  Care 
Act  of  1897  was  passed,  providing  for  county  care.  However,  the 
State  agreed,  under  certain  conditions,  to  pay  $1.75  per  capita, 
per  week,  for  each  patient  cared  for  in  a  county  institution.  The 
conditions  were  rigorous  requirements  as  to  accommodations  pro- 
vided and  treatment  given,  it  evidently  being  feared  that  the 
counties  would  not  provide  the  same  standard  of  care  as  obtained 
in  the  State  hospitals,  and,  as  a  matter  of  fact,  the  counties  found 
it  impossible  to  satisfy  all  such  requirements,  so  the  law  was 
amended,  rendering  the  requirements  less  exacting.  To  further 
assist  the  counties,  in  1899,  the  State  increased  the  weekly  per 
capita  allowance  from  $1.75  to  $2.00.  Thus  it  is  seen  that,  while 
the  State  has  never  assumed  the  full  burden  of  maintenance  of  the 
insane,  it  has  for  many  years  aided  the  counties  in  providing  for 
them,  so  that  what  now  exists  is  a  combined  county  and  State 
system, — the  counties  paying  a  part  of  the  maintenance  of  their 
patients  in  the  State  hospitals,  and  the  State  paying  a  per  capita 
allowance  for  all  patients  in  the  county  and  Poor  District  institu- 
tions. In  each  case  the  difference  between  the  amount  paid  and 
total  cost  of  maintenance  is  made  up  by  the  political  unit  main- 
taining the  institution,  although,  in  the  case  of  the  State  institu- 


tions,  such  difference  must  not  exceed  $2.25  weekly  per  capita, 
the  State  maintenance  appropriation  for  these  institutions  being 
based  on  such  a  fixed  allowance.  Such  a  rate  contrasted  with 
the  $2.00  weekly  per  capita  allowance  to  county  and  Poor  Dis- 
trict institutions  appears  to  imply  a  recognition  by  the  State  of  a 
higher  standard  of  care  in  the  State  hospitals. 

The  existing  system  has  now  been  in  operation  for  a  sufficient 
length  of  time  to  warrant  conclusions  being  drawn  as  to  its  effi- 
ciency as  determined  by  actual  results,  and  it  is  to  such  end 
that  this  inquiry  has  been  directed. 

Aside  from  visits  to  the  31  public  institutions  for  the  insane, 
and  to  the  n  almshouses,  with  insane  inmates,  visits  were  also 
made  to  three  large  private  insane  hospitals,  and  to  three  State 
institutions  for  defectives,  but  this  report  will  be  confined  to  a 
statement  of  conditions  found  in  the  19  county  and  Poor  District 
hospitals,  4  municipal  hospitals,  and  the  n  almshouses  men- 
tioned, the  other  institutions  being  considered  in  supplementary 
reports  I  will  submit  to  your  committee.  However,  for  the  pur- 
pose of  comparison  with  other  types  of  institutions,  a  few  general 
statements  will  be  made  regarding  the  State  hospitals. 

It  was  found  that  the  combined  census  of  the  eight  State  hos- 
pitals in  Pennsylvania,  with  an  official  capacity  of  9,457  beds,  is 
10,474,  but  434  patients  were  found  on  parole  from  the  hospitals, 
and  the  actual  excess  of  patients  over  capacity  would  therefore 
be  583.  This  indicates  but  a  moderate  degree  of  overcrowding — 
but  there  are  but  few  instances,  either  in  State  hospitals  or 
other  institutions  for  the  insane,  of  capacities  having  been 
fixed  in  other  than  an  arbitrary  manner,  depending  upon  the 
exigencies  of  the  situation.  Hence  in  some  hospitals  there 
is  actual  overcrowding  which  is  not  indicated  by  the  official 
figures. 

The  State  hospitals  embrace  the  best  public  institutions  for  the 
care  of  the  insane  in  the  State,  although  facilities  and  standards 
of  care  vary  within  rather  wide  limits.  However,  as  will  be  later 
shown,  they  afford  practically  the  only  opportunity  in  the  State 
of  Pennsylvania  for  a  public  mental  case  to  receive  active  medical 
treatment  directed  to  the  alleviation  or  cure  of  mental  disease. 

In  all  the  State  hospitals  physical  conditions  are  fairly  satis- 
factory, and  in  some  instances  especially  so.  With  numerous 
buildings  it  is  possible  to  classify  patients,  buildings  with  special 

[12] 


facilities  for  special  classes  being  found  in  most  of  these  institu- 
tions. There  are  infirmary  buildings  with  modern  surgical  oper- 
ating rooms,  buildings  for  the  tuberculous,  reception  buildings  for 
new  acute  cases,  convalescent  buildings,  buildings  for  the  dis- 
turbed, and  special  buildings  for  hydrotherapeutic  and  electro- 
therapeutic  treatment,  all  of  which  are  of  importance  in  success- 
fully treating  the  insane. 

In  the  main,  general  hygienic  conditions  are  excellent,  especially 
as  regards  the  provision  of  modern  sewage  disposal  plants. 
Proper  attention  is  generally  given  to  fire  protection,  and  for  the 
most  part  good  service  facilities  are  provided. 

It  is,  however,  in  the  actual  care  and  treatment  of  patients 
that  these  institutions  excel.  With  but  few  exceptions  food  and 
clothing  are  above  criticism,  while  special  attention  is  given  to  ex- 
ercise, recreation  and  occupation.  In  most  of  these  hospitals 
occupation  is  under  medical  direction  and,  being  regarded  only 
as  a  therapeutic  agent,  the  need  of  the  patient  is  paramount  to  the 
need  of  the  work.  In  several  hospitals  special  occupational  train- 
ing is  given  for  the  correction  of  faulty  habits,  and  intensive  per- 
sonal effort  is  made  to  awaken  dormant  interests. 

Most  of  the  hospitals  maintain  nurses'  training  schools,  and  in 
one  over  50  per  cent,  of  the  ward  employees  are  graduate  nurses. 
As  a  result  of  the  substitution  of  nursing  care  for  custodial  care, 
restraint  and  seclusion  have  been  greatly  reduced,  and  in  one 
hospital  entirely  abolished ;  in  another  hospital  restraint  has  been 
reduced  50  per  cent,  during  the  past  year,  and  in  still  another 
25  per  cent,  during  a  recent  period. 

In  some  of  the  hospitals  the  medical  work  is  especially  com- 
mendable. Clinical  and  pathological  laboratories  are  provided, 
and  that  the  latter  have  a  distinct  practical  value  is  shown  at  one 
State  hospital,  where  formerly  typhoid  fever  was  rife  every  year; 
however,  it  no  longer  occurs  since  general  immunization  by  anti- 
typhoid vaccine  has  been  adopted,  the  vaccine  being  prepared  in 
the  hospital  laboratory. 

In  discussing  the  institutions,  of  which  this  report  treats  in 
detail,  it  will,  unfortunately,  be  necessary  to  criticize  more  freely 
to  accurately  indicate  the  conditions  found  to  exist.  But  that  no 
local  authority  may  have  ground  for  just  complaint,  that  the 
comments  made  are  unjustly  discriminatory,  institutions  will  be 
mentioned  by  number  only.  Unfortunately,  however,  those 

[13] 


familiar  with  certain  institutions  will  doubtless  be  able  to  identify 
them,  owing  to  the  necessity  of  discussing  conditions  peculiar  to 
them  alone,  but  as  such  discussion  is  necessary  to  a  proper  under- 
standing of  general  conditions,  the  possibility  of  recognition  of 
identity  of  such  institutions  appears  unavoidable. 

Features  worthy  of  commendation  have  been  noted,  as  well  as 
those  deserving  of  condemnation,  that  a  true  balance  may  be 
reached,  and  from  the  facts  given  only  such  deductions  are  drawn 
as  are  justified  by  actual  conditions. 

As  it  was  found  impossible  to  obtain  accurate  statistics  for  all 
institutions  for  the  same  year,  or  the  same  date,  owing  to  the 
different  hospital  years  in  vogue,  and  also  owing  to  defective 
records,  all  statistical  data  has  been  taken  for  the  last  hospital 
year  available,  while,  as  also  representing  more  accurately  present 
conditions,  all  census  data  has  been  taken  as  of  date  of  visit  to  the 
respective  institutions.  Throughout  the  report  statistics  will  in- 
dicate census  as  the  total  number  on  the  institution  records,  but 
the  number  home  on  parole  will  also  be  indicated,  so  the  actual 
number  in  residence  is  the  difference  between  such  figures. 

INSTITUTIONS  FOR  THE  INSANE  MAINTAINED   BY 
MUNICIPALITIES,  NOS.  7-10 

General  Statistics. — 

Institution  No.  Capacity  Census  On  Parole 

7 1200  1804       24 

8 555  475 

9 650  724       18 

10 300  324       15 

Total 2705  3327  57 

While,  for  the  purpose  of  this  report,  No.  8  is  regarded  as  a 
separate  institution,  it  is  a  branch  of  No.  7,  but  located  at  a  dis- 
tance from  the  main  institution. 

INSTITUTION  No.  7 

Physical  Conditions. — The  ancient,  monasterial  structures  in 
which  this  hospital  is  housed  are  impossible.  They  form  part  of 
a  general  plant,  housing  also  an  almshouse  and  a  general  hospital. 
Light  and  air  are  deficient,  and  in  some  wards  the  day  space  is  so 
limited  that  benches  are  placed  in  rows  across  the  room  to  pro- 

[14] 


vide  sufficient  seating  accommodations.  The  basement  bath- 
rooms are  poorly  lighted  and  ventilated.  The  old,  unsanitary 
and  insufficient  toilet  facilities  are  now  being  replaced.  The 
service  departments  are  all  cramped  for  space.  The  fire  pro- 
tection could  be  improved,  several  iron  fire-escapes  having  wooden 
platforms.  Some  of  the  stone  stairways  are  enclosed  in  wooden 
towers  and  others  lead  to  the  cellar  only. 

Overcrowding  is  of  a  serious  degree.  In  some  places  beds  ac- 
tually touch.  One  ward  is  so  completely  filled  with  beds  that 
but  a  narrow  space  remains  between  them  and  the  four  side  walls 
for  day  space.  In  view  of  existing  conditions,  it  is  difficult  to 
understand  how  this  hospital  could  have  cared  for  several  hun- 
dred more  patients,  as  is  said  to  have  been  the  case  some  years 
ago.  To  accentuate  the  poor  housing  conditions,  there  is  but 
limited  space  for  outdoor  exercise  and  there  are  but  limited  facili- 
ties for  occupation.  On  occasion  of  visit  but  28  per  cent,  of  the 
patients  were  occupied  for  even  part  of  the  time. 

Despite  these  adverse  conditions,  the  housekeeping  is  excel- 
lent and  commendable  evidence  of  initiative  was  seen  in  the  use 
of  sanitary  bubbling  drinking  fountains,  built  by  hospital  labor 
from  old  pipes. 

Administration. — The  medical  work  appears  fairly  efficient  and 
the  use  of  a  social  worker  as  an  "after-care"  agent  is  praise- 
worthy. There  is  a  large  number  of  patients  (an  average  of  77) 
either  restrained  or  secluded,  as  a  result  of  an  undue  proportion  of 
disturbed  patients  and  too  small  a  proportion  of  attendants. 
The  number  of  attendants  on  duty  on  day  of  visit  gave  a  propor- 
tion of  but  one  attendant  to  15  patients,  a  proportion  too  small, 
especially  in  view  of  existing  material  conditions.  The  small 
number  of  attendants  may  partly  account  for  an  apparent  failure 
to  use  hydrotherapeutic  facilities  to  capacity,  especially  the  con- 
tinuous baths. 

That  the  large  proportion  of  disturbed  patients  is  directly  due 
to  the  faulty  conditions  appears  evident  in  view  of  the  result  fol- 
lowing a  transfer  of  patients  to  one  of  the  State  hospitals  (No.  17). 
By  special  arrangement  a  large  number  of  disturbed  and  destruc- 
tive patients  were  included,  yet,  with  improved  housing  condi- 
tions and  much  outdoor  exercise,  the  majority  became  quiet 
within  a  few  months  and  not  a  few  became  industrious. 

The  adverse  conditions  must  also  be  held  accountable,  in  a 


measure  at  least,  for  the  abnormally  high  death  rate  of  9.9  per 
cent,  based  on  the  total  number  of  patients  treated,  and  the  ab- 
normally low  recovery  rate  of  7.3  per  cent,  based  on  the  number 
of  persons  admitted. 

The  business  methods  here  in  vogue  are  defective ;  too  small  a 
stock  of  supplies  is  carried  ahead,  with  the  result,  for  example, 
that  some  months  ago  it  was  necessary  to  accept  shoes  said  to  be 
worth  at  least  a  dollar  less  than  the  sample  shoes  on  which  the 
contract  had  been  awarded.  The  situation  was  such  that  either 
the  patients  had  to  go  without  shoes  or  the  delivery  had  to  be 
accepted,  and  the  latter  course  was  followed. 

A  non-medical  superintendent  is  in  charge  of  this  hospital. 

All  the  patients  admitted  pass  through  a  psychopathic  ward, 
which  at  the  time  of  visit  was  most  crude  and  without  facilities, 
but  changes  have  since  been  effected,  improving  the  situation. 

INSTITUTION  No.  8 

Physical  Conditions. — This  is  in  a  rural  locality  and  somewhat 
difficult  of  access.  The  patients'  quarters  are  for  the  most  part 
in  converted  farmhouses,  which,  in  the  absence  of  equipment, 
furnish  rather  crude  accommodations,  but  permit  a  large  measure 
of  freedom,  with  excellent  opportunity  for  exercise  and  occupa- 
tion, as  is  shown  by  the  fact  that  48  per  cent,  of  the  population 
are  regularly  employed,  the  majority  of  the  remainder  being 
tubercular  and  aged,  decrepit  patients.  The  chief  defects  are 
the  crude  service  accommodations,  an  insufficient  water  supply, 
great  fire  risk,  and  an  unsanitary  method  of  sewage  disposal, 
cesspools  being  used  which  are  too  close  to  the  buildings,  one 
being  not  far  from  the  dairy  barn.  Water  mains  and  sewer 
mains  are  being  laid,  however,  and  if  properly  completed,  will  no 
doubt  provide  an  adequate  water  supply  and  a  sanitary  system 
of  sewage  disposal. 

Administration. — Except  for  strictly  medical  matters,  the  head 
farmer  is  in  charge,  reporting  directly  to  the  lay  superintendent  at 
the  mother  institution,  No.  7.  There  is  evidence  that  more  or 
less  friction  exists  between  the  medical  and  farm  service.  The 
method  of  handling  supplies  does  not  appear  to  sufficiently  safe- 
guard the  interests  of  the  institution,  for,  while  cost  records  are 
kept,  unit  records  of  articles  are  not. 

[161 


INSTITUTION  No.  9 

Physical  Conditions. — This  institution  forms  one  unit  of  a 
plant  composed  also  of  a  general  hospital,  almshouse,  and  tuber- 
cular colony.  The  buildings  are,  in  the  main,  satisfactory. 
However,  in  the  older  buildings  a  number  of  archaic  features  are 
to  be  noted.  Several  rooms  are  equipped  with  concrete  floors, 
with  center  drains,  similar  to  a  stable.  They  are  also  provided 
with  double,  heavy,  solid  doors,  thus  providing  for  seclusion.  For 
the  most  part,  the  wards  are  bare,  lack  furniture,  and  are  desolate 
in  appearance.  Insufficient  heat  is  provided,  and  last  year  it  is 
said  to  have  been  necessary  for  patients  and  attendants  to  wear 
overcoats  and  shawls  indoors.  The  exercise  yards  are  objection- 
able, being  enclosed  with  high,  whitewashed,  board  fences,  so 
closely  fitted  as  to  shut  off  any  outside  view.  The  grass  has  been 
worn  off,  and  during  the  absence  of  the  women  from  their  yard, 
eighteen  large  rats  were  counted  running  about  in  it. 

Administration. — The  patients  have  access  to  running  hot 
water,  although  no  hot  water  safety  devices  are  provided;  as  a 
result  a  woman  patient  was  so  severely  scalded  a  year  ago  that  she 
died  following  the  burns.  However,  despite  the  subsequent 
recommendation  of  the  State  Committee  on  Lunacy  that  a  safety 
device  be  installed,  no  action  has  ever  been  taken.  On  occasion 
of  visit,  there  were  23  patients  either  restrained  or  secluded,  12 
of  whom  are  constantly  restrained.  Even  such  a  large  number 
is  much  less  than  a  few  years  ago.  In  1911,  with  a  smaller 
census  than  at  present,  the  average  number  of  patients  re- 
strained and  secluded  is  given  as  from  40  to  50.  There  are  but 
20  per  cent,  of  the  patients  regularly  occupied,  despite  the  fact 
that  there  is  a  large  farm  and  plenty  of  opportunity.  However, 
the  policy  heretofore  has  been  to  use  the  labor  of  the  pauper  in- 
mates of  the  adjoining  almshouse  before  endeavoring  to  provide 
occupation  for  the  insane.  There  has  been  a  great  lack  of  per- 
sonal care  and  attention,  as  must  necessarily  be  the  case  with 
the  unusually  low  proportion  of  attendants.  On  day  of  visit 
there  was  but  one  attendant  to  23  patients  for  day  duty  and  one 
to  90  for  night  duty.  The  medical  work  has  heretofore  been  on  a 
low  plane  of  efficiency,  as  could  scarcely  be  otherwise,  when  dur- 
ing the  past  year,  except  for  a  few  weeks,  but  two  physicians  were 
provided  to  care  for  from  1200  to  1400  patients,  the  physicians 
attached  to  this  institution  being  obliged  to  care  not  only  for  the 

[17] 


insane,  but  also  for  over  50  tuberculous  patients,  over  200  general 
hospital  patients,  and  nearly  300  almshouse  inmates,  all  housed 
in  adjoining  buildings. 

The  future  of  this  institution  promises  better  things.  A  new 
medical  superintendent  has  recently  been  appointed,  replacing  a 
non-medical  superintendent.  The  new  appointee  fully  appre- 
ciates existing  needs  and  has  already  instituted  improvements, 
while  he  plans  many  more.  The  dietary  has  been  improved  and  a 
departure  has  been  made  from  the  routine  bread,  molasses  and 
tea  diet  for  breakfast  and  supper,  formerly  provided.  Already 
provision  has  been  made  for  proper  reception  wards  for  new 
patients,  heretofore  lacking,  while  hydrotherapy  is  to  be  installed, 
the  work  of  reeducational  occupation  is  to  be  inaugurated,  and 
the  lack  of  recreation  to  be  supplied.  The  number  of  medical 
men  has  been  increased;  a  laboratory  is  to  be  started,  and,  in 
general,  it  may  be  confidently  expected  that  this  institution  will 
enter  upon  a  new  era.  It  may  likewise  be  expected  that  as  a  re- 
sult of  active  curative  treatment  for  insanity  there  will  be  a  fair 
percentage  of  recoveries,  instead  of  no  recoveries  at  all,  as  has 
been  the  case  since  1907.  The  latter  condition  has  obtained, 
despite  the  fact  that  during  the  past  hospital  year  alone  there 
were  66  cases  admitted  suffering  from  such  recoverable  psychoses 
as  would  under  proper  treatment  yield  a  recovery  rate  of  from 
85  to  90  per  cent.  It  is  therefore  to  be  most  earnestly  hoped  that 
the  new  medical  spirit  now  in  evidence  may  receive  every  possible 
support. 

INSTITUTION  No.  10 

Physical  Conditions. — The  buildings  are  good,  but  are  located 
adjacent  to  a  County  Workhouse,  the  latter  being  but  about  100 
yards  from  the  building  for  insane  women,  and  just  across  a  road- 
way from  their  exercise  yard.  The  two  buildings  for  opposite 
sexes  are  separated  by  an  almshouse,  in  which  are  the  administra- 
tive offices  of  the  hospital.  The  exercise  yards  are  enclosed  with 
a  high  board  fence,  thus  emphasizing  the  idea  of  restraint,  so 
pernicious  in  its  effects  upon  insane  patients. 

Administration. — The  executive  head  is  a  non-medical  man  and 
the  usual  objections  apply  with  even  more  than  usual  force,  owing 
to  the  superintendent's  lack  of  familiarity  with  the  details  of  the 
hospital,  evidenced  by  supplying  considerable  information  later 

[18] 


found  to  be  erroneous.  The  housekeeping  of  the  wards  is  excel- 
lent, but,  aside  from  the  farm  and  the  engineer's  department,  all 
the  service  departments  were  found  in  very  poor  order.  There 
are  no  formal  amusements  for  the  patients,  and  even  those 
patients  fortunate  enough  not  to  be  restrained  lead  a  drab,  color- 
less existence,  but  the  amount  of  restraint  used  appears  unwar- 
ranted. On  the  day  of  the  visit  there  were  thirty-one  patients,  or 
10  per  cent,  of  the  total  hospital  population,  either  restrained  or 
secluded,  while  eighteen  patients,  or  5.8  per  cent.,  are  constantly 
restrained  or  secluded.  In  making  rounds  most  of  such  pa- 
tients were  found  absolutely  quiet,  two  only  being  moderately 
restless.  It  was  said  that  in  most  cases  such  treatment  was  used 
because  the  patients  had  previously  been  disturbed.  It  cannot 
be  without  significance  that  the  lay  superintendent  occasionally 
orders  both  restraint  and  seclusion,  without  consultation  with 
the  physician.  The  amount  of  restraint,  however,  appears  in  a 
measure  due  to  the  limited  proportion  of  attendants,  there  being 
on  duty,  on  the  day  of  the  visit,  but  one  attendant  to  fifteen 
patients  for  day  duty.  Such  lack  was  also  given  as  the  reason  for 
the  limited  amount  of  outdoor  exercise,  patients  never  being 
out  longer  than  two  hours  in  any  one  day,  even  in  good  weather. 

While,  in  the  main,  the  separation  of  the  sexes  is  good,  there  is 
some  opportunity  for  improper  mingling  of  sexes,  as  was  shown 
when  two  working  patients,  a  man  and  a  woman,  were  found 
eating  together  in  a  room  off  the  kitchen,  without  an  attendant 
present. 

The  food  service  is  poor  and  the  dietary  is  stereotyped.  All 
kinds  of  food  are  heaped  on  a  single  plate  for  each  patient.  For 
the  meal  inspected,  after  soup  had  been  placed  in  deep  plates,  a 
piece  of  meat  and  sliced  green  cucumbers  were  added,  and  it  was 
noticeable  that  as  soon  as  the  patients  were  seated  a  piece  of 
bread  was  used  as  an  auxiliary  plate. 

The  institution  lacks  any  hydrotherapeutic  equipment  or  pro- 
visions for  special  medical  treatment,  and  there  is  no  treatment  of 
insanity  as  such.  The  result  is  seen  in  the  remarkably  low  re- 
covery rate  of  2.8  per  cent.,  based  on  admissions.  During  the 
last  hospital  year,  thirty-one  cases  were  received  suffering  from  a 
certain  recoverable  form  of  mental  disease,  which,  under  proper 
treatment,  would  have  yielded  a  recovery  rate  of  85  to  90  per 
cent.,  but  among  the  cases  discharged  as  recovered  from  this 

[19] 


institution  there  was  but  a  single  patient  discharged  recovered 
who  had  suffered  from  such  type  of  mental  trouble.  Tubercular 
patients  mingle  with  the  others  until  they  become  bedfast,  when 
they  are  cared  for  in  the  neighboring  almshouse,  which  alone  has 
facilities  for  isolation.  There  were  several  insane  patients  resid- 
ing in  the  almshouse  on  the  occasion  of  the  visit,  including  not 
only  tubercular  cases,  but  a  surgical  case,  the  almshouse  alone 
possessing  facilities  for  the  treatment  of  surgical  conditions.  The 
clinical  records  are  poor,  but  the  medical  force  is  too  small  to 
perform  properly  the  medical  work  in  this  institution,  with  324 
insane  patients,  and  also  in  the  almshouse,  with  201  inmates,  as  is 
required,  there  being  but  two  physicians. 

One  of  the  deplorable  features  of  this  institution  is  that  there  is 
reason  to  believe  that  political  influences  have  heretofore  oper- 
ated in  the  selection  of  employees,  and  the  resulting  inefficiency 
of  attendants  thus  selected  is  shown  in  the  following  instances : 
One  attendant  caring  for  a  sick  patient  reported  a  temperature  of 
1000  degrees;  another,  when  told  to  get  a  bottle  of  ammonium 
chloride  tablets  brought  bichloride  of  mercury  tablets  instead, 
believing  all  chlorides  were  the  same.  The  superintendent  him- 
self admitted  it  was  sometimes  possible  to  find  attendants  on  duty 
partially  intoxicated,  but  said  it  was  no  use  to  dismiss  them,  as  it 
would  only  mean  replacing  them  with  others  of  the  same  caliber. 
During  visit  a  death  was  reported  to  the  office,  but  a  few  minutes 
later  it  was  reported  to  be  a  false  alarm.  It  appeared  that  an 
attendant  had  been  deceived  when,  in  cleaning  the  bed  of  a  sick 
patient,  he  had  laid  the  patient  on  the  cold  concrete  floor,  where- 
upon the  shock  of  such  treatment  caused  collapse.  As  a  matter 
of  fact,  however,  the  patient  was  actually  in  a  dying  condition 
and  expired  later  the  same  afternoon. 

This  institution  is  to  be  moved  to  and  consolidated  with  No.  9 
as  soon  as  new  buildings  have  been  there  erected,  a  change  which 
must  necessarily  result  for  the  patients'  good. 


SUMMARY  OF   INSTITUTIONS   MAINTAINED   BY 
MUNICIPALITIES 

Institution  No.  7  is  so  unsuited  architecturally  for  the  care  and 
treatment  of  insane  patients  that  its  use  should  be  abandoned  at 
the  earliest  possible  moment.  The  great  overcrowding  here 

[20] 


existing  only  emphasizes  structural  defects.  The  abnormally 
high  death  rate  must,  in  part  at  least,  be  caused  by  structural 
conditions,  as  the  medical  work  appears  fairly  efficient. 

Institution  No.  8,  a  branch  of  No.  7,  provides  the  great  boon  of 
outdoor  exercise  and  occupation  lacking  in  the  latter.  Methods 
of  transportation  are  not  yet  adequate,  the  accommodations  are 
crude,  the  water  supply  is  deficient,  and  the  sewage  disposal  is 
unsanitary,  although  the  two  defects  last  mentioned  will  ap- 
parently be  remedied  by  the  completion  of  plans  now  under  way. 
The  fire  risk  is  considerable.  The  defects  and  disadvantages 
indicated  are  all  remediable,  however,  and  there  would  seem  to 
be  marked  possibilities  for  this  institution  under  State  rather 
than  municipal  control. 

Institution  No.  9  has  heretofore  provided  only  the  most  crude 
custodial  care.  The  fact  that  no  patients  have  been  discharged 
as  recovered  for  7  years  tells  the  whole  tale;  however,  a  new 
administration  has  been  inaugurated,  and  there  is  reason  for 
believing  that  not  only  will  the  material  condition  of  patients  be 
improved,  but  that  in  the  future  they  will  receive  active  medical 
treatment  directed  to  the  alleviation  of  their  mental  ills,  some- 
thing never  before  provided  in  this  institution. 

Institution  No.  10  is  poorly  located,  being  in  association  not 
only  with  an  almshouse  but  with  a  County  Workhouse.  While 
the  buildings  are  good,  there  are  no  facilities  for  the  medical 
treatment  of  insanity  and  even  in  the  treatment  of  physical  ills 
the  baneful  practice  has  arisen  of  treating  surgical  and  advanced 
tubercular  cases  in  the  almshouse,  where  no  distinction  is  made 
between  them  and  the  paupers.  Under  the  circumstances,  it 
appears  fortunate  that  this  hospital  is  to  be  consolidated  with 
No.  9. 

General  Considerations. — In  reviewing  the  conditions  found  in 
this  group  of  institutions  it  would  appear  that  none  have  been 
properly  performing  their  function  as  institutions  for  the  treat- 
ment and  possible  cure  of  insanity.  Political  and  secular  inter- 
ests have  apparently  submerged  the  medical  spirit,  and  as  a  result 
it  is  certain  that  many  unfortunate  insane  persons  have  failed  of 
recovery  through  lack  of  proper  medical  facilities  and  treatment. 
The  conviction  appears  irresistible  that  whatever  may  have  been 
past  policies  the  welfare  of  the  community  would  be  best  served 
by  removing  these  hospitals  from  municipal  control. 

[21] 


LICENSED  COUNTY  INSTITUTIONS  FOR  INSANE. 

NOS.  19-37 
General  Statistics. — 

Institution 

number           Capacity  Census       On  parole 

19 42  43  2 

20 800  886  93 

21 203  286  24 

22 None  for 

insane  8  o 

23 305  294  6 

24 107  89  9 

25 50  26  o 

26 25  29  i 

27 48  44  2 

28 50  46  o 

29 64  69  o 

30 530  517  9 

31 300  364  42 

32 600  621  17 

33 132  114  i 

34 40  39  ° 

35 5oo  481  25 

36 229  240  9 

37 96  IQ7  _5 

Total 4121  4303          245 

INSTITUTION  No.  19 

Physical  Conditions. — Building  for  insane  at  rear  of  alms- 
house,  with  earth  yard  in  front.  It  is  in  good  repair.  The  halls, 
however,  are  too  narrow.  There  is  no  regular  dining-room,  a 
short  hall  serving  this  purpose,  in  which  both  sexes  eat  at  the 
same  table.  The  "cells"  for  seclusion  have  concrete  floors  and 
are  double-d cored,  the  inner  door  being  iron-barred  and  the 
outside  one  of  heavy  wood.  One  of  these  outside  doors  has 
been  removed,  leaving  only  the  iron-barred  door  in  sight  and  thus 
emphasizing  the  prison  effect.  Electric  lights  are  used,  but  wiring 
is  attached  to  surface  of  walls  in  such  a  way  as  to  be  accessible  to 
patients.  Wards  are  bare  and  without  sufficient  seating  facili- 
ties, so  that  when  all  patients  are  indoors  it  is  necessary  to  use 
backless  benches  from  the  dining-room.  Much  trouble  is  said 
to  have  been  experienced  from  patients  sitting  on  the  flat  tops  of 
screened  radiators,  and  local  authorities  have  recommended  that 
a  sloping  top  be  substituted,  but  additional  seating  facilities  do 
not  appear  to  have  been  suggested. 

There  are  but  two  wards  for  each  sex,  so  that  little  classifica- 
tion of  patients  is  possible.  Fire  protection  is  insufficient. 

[22] 


Sewage  flows  untreated  into  an  open  ditch  about  150  yards  from 
the  main  building;  when  seen  this  ditch  was  absolutely  stag- 
nant. Piggery  is  within  200  yards  of  building  for  insane,  and 
not  overclean. 

Small  exercise  yard  for  each  sex  is  enclosed  by  high,  white- 
washed board  fence,  partly  surmounted  by  barbed  wire,  the  gate 
to  each  yard  being  fastened  with  a  padlock. 

In  many  respects  almshouse  building  is  superior  to  that  for 
insane. 

Administration. — Women  live  on  second  floor,  but  stair  doors 
are  left  unlocked  and  separation  of  sexes  is  poor.  Women  pa- 
tients were  found  doing  housework  in  the  male  wards,  without 
any  attendant,  although  male  patients  were  present.  There  is 
but  a  single  married  couple  for  day  duty  and  another  such  couple 
for  night  duty.  Patients  are  left  alone  much  of  the  time.  Those 
in  the  exercise  yards  when  once  locked  in  are  left  unattended. 
In  one  of  these  yards  five  concentric  rings  have  been  beaten  in 
the  earth  about  a  tree  by  the  ceaseless  pacing  of  patients. 

Dining-room  service  is  crude.  Food  is  brought  in  tin  buckets 
from  the  almshouse.  In  good  weather  some  of  patients  eat  on 
the  ground  in  the  exercise  yards.  Most  of  dishes  are  of  agate 
ware.  Food  is  sufficient  in  amount  but  of  limited  variety. 
Bread,  molasses,  and  tea  or  coffee  are  the  staples  for  both  morning 
and  evening  meals,  the  dietary  being  the  same  as  for  the  aims- 
house. 

The  men's  clothing  is  of  overall  material,  suits  being  made  in 
almshouse  and  little  attention  paid  to  fit.  A  number  of  patients 
were  barefooted,  and  from  appearance  of  feet,  had  been  so  for 
many  weeks.  There  are  no  recreations  provided,  and  but  three 
or  four  patients  attend  the  occasional  religious  services  conducted 
by  volunteers  in  the  almshouse. 

The  visiting  physician  calls  once  a  week,  but  only  physical 
ills  receive  attention.  The  physician  refuses  to  pull  teeth,  and 
after  hearing  a  woman  patient  weep  all  night  with  the  toothache, 
the  "keeper"  for  the  first  time  in  his  life  pulled  a  tooth.  He  has 
since  pulled  two  more.  "Keeper"  was  formerly  a  farmer;  he 
uses  his  own  judgment  in  the  matter  of  restraint  and  seclusion. 
In  his  opinion,  two  days  in  a  strait-jacket  is  enough  "to  make 
them  come  down."  Seclusion,  however,  is  sometimes  used  from 
six  to  eight  weeks,  or  even  longer. 

[23] 


A  woman  patient  has  an  open,  undressed  cancer,  and  another 
woman  patient  has  recurring  ulcerations  of  the  nose,  apparently 
of  luetic  origin.  Neither  these  patients  nor  the  single  tuber- 
cular patient  here  are  isolated,  but  mingle  freely  with  the  others. 

A  particularly  reprehensible  practice  in  this  community  is  the 
custom  of  committing  insane  patients  to  the  State  Hospital  only 
if  they  belong  to  one  of  the  "better  families"  or  if  they  are  par- 
ticularly disturbed  or  troublesome. 

The  neighboring  almshouse  is  crowded  every  winter,  and  the 
present  building  for  the  insane  could  be  used  to  advantage  for 
the  paupers  were  the  insane  removed,  as  they  should  be. 

INSTITUTION  No.  20 

Physical  Conditions. — The  buildings  are  excellent,  thoroughly 
fire-proof,  and  the  grounds  ample.  While  some  wards  are  bare, 
others  have  decorative  features.  Sanitary  bubbling  drinking- 
fountains  are  a  commendable  provision.  The  numerous  wards 
offer  a  good  opportunity  for  classification.  In  general,  service 
departments  are  good,  but  the  laundry  is  too  small  and  some  of 
the  departments  are  poorly  located  in  basements.  Farm  build- 
ings are  excellent.  Sewage  flows  untreated  into  a  neighboring 
creek.  Fire  protection  could  be  improved,  too  much  reliance 
being  placed  on  exterior  fire-proof  construction.  For  instance, 
a  third-floor  dormitory  with  about  100  patients  has  but  a  single 
exit  to  a  stairway,  although  outside  is  an  iron  fire-escape  which  is 
inaccessible,  as  the  oval  window  leading  to  it  is  guarded  by  per- 
manently fastened  iron  bars. 

All  exercise  yards  are  enclosed,  one  with  a  high,  whitewashed 
board  fence  surmounted  by  barbed  wire,  while  another  is  a  court 
covered  with  stone  flagging  and  enclosed  by  an  iron  fence  sur- 
mounted by  barbed  wire. 

The  buildings  of  the  neighboring  almshouse  are  especially 
good  and  well  adapted  for  the  care  of  the  insane,  one  building 
being  so  used.  Were  the  almshouse  and  insane  hospital  consoli- 
dated there  would  no  longer  exist  the  necessity  for  two  laundries, 
two  direct  refrigeration  plants,  two  store  rooms,  two  drug  rooms, 
two  power  plants,  two  carpenter  shops,  two  paint  shops,  and  two 
plumbers'  shops. 

Administration. — A  fair  grade  of  custodial  care  is  here  given, 
but  the  non-medical  character  of  the  institution  is  shown  in  its 

[24] 


annual  report,  the  only  medical  feature  of  which  is  a  table  show- 
ing causes  of  death.  Physical  ills  receive  proper  treatment,  but 
there  are  no  facilities  nor  treatment  for  insanity  as  such. 

Owing  to  overcrowding  and  the  comparatively  small  propor- 
tion of  attendants,  restraint  is  much  used,  the  overcrowding 
being  especially  apparent  in  the  disturbed  wards.  A  particu- 
larly objectionable  form  of  restraint  is  a  long-sleeved  coat,  by 
means  of  which  patients'  arms  are  tied  behind  their  back. 

Tubercular  cases  are  scattered  throughout  the  various  wards, 
although  it  is  proper  to  add  that  new  construction  now  going  on 
will  provide  excellent  facilities  for  the  isolation  of  tubercular 
patients. 

With  material  facilities  in  general  of  an  unusually  good  grade, 
the  whole  plant  could  be  utilized  to  the  greatest  advantage  as 
an  institution  solely  for  the  insane. 

INSTITUTION  No.  21 

Physical  Conditions. — A  fairly  satisfactory  fire-proof  building 
is  provided,  many  defects  of  which  could  be  overcome  by  the 
expenditure  of  small  amounts  of  money.  Hospital  is  over- 
crowded, and  as  a  direct  result  there  is  insufficient  day  space. 
Fly-screens  throughout  constitute  an  excellent  feature.  Wom- 
en's wards  have  some  decorative  features,  but  men's  wards  are 
bare  and  have  but  few  chairs,  backless  benches  being  substituted. 
The  outside  entrances  have  iron-barred  doors  outside  of  wooden 
ones,  so  when  the  latter  are  left  open  for  ventilation  an  unpleasant 
prison-like  effect  is  produced.  There  are  a  few  unprotected 
radiators  on  the  floor,  but  most  are  placed  on  the  walls  out  of 
reach. 

There  is  a  great  lack  of  space  for  service  departments,  most  of 
them  being  crowded  into  small  basement  rooms.  Another  serious 
lack  is  the  want  of  land,  the  hospital  having  but  a  small  plot  set 
apart  for  its  use  out  of  the  entire  county  property,  the  remainder 
being  devoted  to  the  use  of  the  neighboring  almshouse. 

Sewage  flows  untreated  into  a  river  about  a  half  mile  distant. 
There  is  a  serious  lack  in  the  want  of  sufficient  water  supply. 
During  the  past  summer  water  pressure  has  been  insufficient 
to  fill  the  service  lines  on  the  second  floor,  so  water  has  had  to 
be  carried  upstairs  by  hand  in  pails  for  all  purposes.  Despite  the 
increased  fire  risk,  authorities  are  said  to  have  made  no  effort  to 

[25] 


remedy  conditions  although  it  would  appear  easily  possible  to  do 
so,  and  although  the  superintendent  of  the  hospital  has  repeat- 
edly urged  it.  There  is  already  a  well  on  the  property  giving  an 
abundant  flow  of  good  water,  but,  owing  to  a  failure  to  provide  a 
sufficiently  powerful  pump,  little  relief  is  thus  obtained. 

The  neighboring  almshouse  is  in  fair  condition,  and  at  an  ex- 
penditure of  from  five  to  six  thousand  dollars  could  be  rendered 
available  for  the  care  of  the  insane.  The  condition  here  presents 
a  striking  contrast  to  that  of  the  insane  hospital,  for  instead  of 
being  greatly  overcrowded,  as  is  the  latter,  less  than  half  its 
capacity  is  now  utilized. 

Administration. — With  but  two  wards  for  each  sex,  little  classi- 
fication is  possible.  There  is  an  unusually  good  dietary.  As 
result  of  overcrowding  and  an  insufficient  number  of  attendants, 
restraint  and  seclusion  are  frequently  used.  Despite  efforts  of 
the  medical  superintendent,  it  has  been  impossible  to  secure  hy- 
drotherapeutic  apparatus  or  any  special  medical  equipment. 
There  are  but  two  tubercular  cases,  who  are  allowed,  however, 
to  mingle  with  the  other  patients. 

An  excellent  feature  of  this  institution  is  the  degree  to  which 
occupation  for  patients  has  been  developed  under  adverse  con- 
ditions. Those  who  work  on  the  farm  do  so  under  the  direction 
of  the  almshouse  steward,  so  that  the  hospital  superintendent  has 
to  exercise  care  as  to  the  patients  sent  out  for  such  work,  having 
no  knowledge  of  what  tasks  they  will  have  to  do.  The  superin- 
tendent is  probably  correct  in  believing  that  more  patients  could 
be  allowed  the  benefit  of  farm  work  if  he  had  the  authority  to 
regulate  tasks  to  their  varying  capacities.  It  is  unfortunate 
that  so  many  of  the  patients  working  in  the  service  departments 
are  obliged  to  work  in  the  basement  where  light  and  air  are  de- 
ficient. 

Unusually  close  accounts  are  kept.  The  hospital  is  obliged 
to  pay  the  almshouse  for  bread,  milk  and  pork,  although  it  re- 
ceives no  compensation  in  return  for  the  labor  of  patients  and 
attendants.  A  large  number  of  reimbursing  patients  makes 
this  institution  self-supporting,  aside  from  State  aid. 

Although  the  superintendent  is  a  physician,  he  has  no  medical 
assistants,  and  but  little  help  in  business  matters,  so  it  would 
appear  impossible  for  him  to  give  as  much  attention  to  medical 
matters  as  would  seem  desirable. 

[26] 


The  material  conditions  of  the  plant,  as  a  whole,  including 
almshouse,  are  such  that  it  could  be  rendered  available  for  the 
care  of  the  insane  at  comparatively  small  expense,  as  most  de- 
fects noted  are  removable  ones. 

INSTITUTION  No.  22 

Physical  Conditions. — The  insane  are  kept  in  the  almshouse 
proper,  separate  corridors  being  reserved  for  them,  although  in 
practice  they  freely  mingle  with  the  paupers  and  with  a  consider- 
able number  of  defectives;  the  only  discernible  difference  in 
treatment  is  that  they  are  allowed  less  freedom.  Rooms  for  the 
insane  have  iron  bars  over  windows,  while  the  doors  are  heavy 
wood  with  iron  braces ;  in  the  center  of  each  door  is  an  aperture 
covered  by  an  iron  grating,  with  a  wooden  slide  for  a  peek  hole, 
while  lower  down  in  the  door  is  an  open  aperture  through  which 
food  is  introduced  when  an  excited  patient  is  secluded.  Doors 
are  fastened  with  heavy  padlocks. 

Although  exercise  yards  are  enclosed,  they  are  unusually  pleas- 
ant for  such  type  of  yards.  A  philanthropic  neighbor  has  built 
an  excellent  small  chapel  divided  for  Protestant  and  Catholic  ser- 
vices. There  is  an  excellent  farm  with  good  farm  buildings. 

Fire  risk  appears  especially  great.  The  illumination  is  by 
open  flame,  gasoline  gas-jets.  Water  pressure  is  sufficient  onl^ 
to  carry  water  to  the  second  floor.  Buildings  are  old,  and  it 
appears  doubtful  whether  inmates  on  the  third  and  fourth  floors 
could  escape  in  case  of  fire,  despite  the  fact  that  there  are  a  few 
fire-escapes  provided. 

Administration. — Separation  of  sexes  is  poor;  they  occupy 
different  floors,  but  the  stairs  are  open  during  the  day.  But 
limited  paid  help  is  provided,  and  in  practice  the  paupers  do  con- 
siderable of  the  work  in  caring  for  the  insane. 

A  humane  atmosphere  exists  in  this  institution,  and  restraint 
and  seclusion  are  little  used;  however,  both  may  be  used  at  the 
discretion  of  the  woman  nurse  or  the  almshouse  steward,  and 
shortly  prior  to  visit  a  male  patient  was  said  to  have  been  se- 
cluded for  a  week.  There  is,  of  course,  no  medical  treatment  for 
insanity  as  such,  and  even  provision  for  the  treatment  of  physical 
ills  is  limited,  the  visiting  physician  making  regular  visits  once  a 
week  only. 

The  donor  of  the  chapel  above  mentioned  had  engaged  an  in- 

[27] 


structor  in  raffia  and  reed  basketry,  who  was  found  teaching  such 
craft  to  a  number  of  the  pauper  inmates  and  to  one  insane  patient, 
but  in  general  the  insane  are  little  occupied. 

INSTITUTION  No.  23 

Physical  Conditions. — The  building  provided  is  excellent; 
it  is  fire-proof  and  well  arranged.  There  is  also  an  excellent  farm, 
but  it  is  conducted  by  the  steward  of  the  neighboring  almshouse. 
This  almshouse  building,  while  old,  is  remarkably  well  preserved. 
Institution  has  a  good  modern  sewage  disposal  plant.  Fire  pro- 
tection is  fair,  but  hose  is  not  tested,  matters  of  this  kind  being 
in  charge  of  the  almshouse  steward.  The  hospital  superintendent 
is  said  to  have  repeatedly  requested  such  tests. 

Hospital  lacks  space  for  service  departments,  most  of  them 
being  located  in  the  basement.  There  is  an  excellent  detached 
building  provided  as  a  home  for  women  attendants.  This  in- 
stitution is  notable  in  that  although  it  is  a  county  institution  it 
possesses  no  enclosed  exercise  yard. 

Administration. — The  hospital  superintendent  is  a  physician, 
and  all  business  matters  are  under  the  direction  of  the  almshouse 
steward,  who  has  authority  t©  revise  superintendent's  requests 
for  supplies. 

There  is  no  laboratory,  hydrotherapeutic  equipment,  nor 
medical  treatment,  except  that  directed  to  the  alleviation  of 
physical  ills  only. 

Except  in  the  severest  winter  weather  heat  is  said  to  be  shut 
off  from  9.00  P.  M.  to  5.00  A.  M.;  it  was  admitted  that  patients 
often  complain  of  the  cold,  when  they  are  supplied  with  extra 
blankets.  Patients  are  for  the  most  part  locked  in  their  rooms 
at  night.  Several  were  also  found  locked  in  their  rooms  during 
the  day.  A  tubercular  girl  was  found  locked  in  her  room  on  the 
second  floor  with  no  attendant  on  the  floor.  Patient  was  weak, 
confined  to  bed,  and  there  appeared  no  apparent  justification 
for  her  seclusion,  unless  it  was  to  prevent  her  from  wandering 
about  the  ward,  although  in  her  weak  condition  she  showed  no 
such  tendency;  moreover,  two  ambulatory  tubercular  cases 
mingle  with  the  other  patients  without  restriction.  An  elderly 
woman,  moaning  and  protesting  loudly,  was  found  secluded; 
when  her  room  was  entered  and  she  was  addressed,  she  became 
somewhat  quieter  and  there  appeared  no  doubt  that  could  she 

[28] 


have  received  adequate  personal  attention  her  agitated  depres- 
sion would  have  been  much  lessened.  Another  secluded  woman 
was  said  to  have  been  homicidal;  but  when  addressed,  she  ex- 
plained, with  a  smile,  that  sometimes  the  voices  called  her  such 
bad  names  she  could  not  help  but  get  angry,  although  she  did  not 
mean  harm  to  anybody.  Two  women  were  found  locked  in  a 
bathroom,  but  for  what  reason  did  not  appear,  as  both  were  quiet. 
Both  restraint  and  seclusion  are  ordered  by  the  matron,  who  then 
reports  to  the  superintendent. 

Recreation  is  given  some  attention  in  this  institution,  and  in 
many  respects  the  custodial  care  provided  is  of  a  fair  type. 

Material  conditions  both  at  the  insane  hospital  and  the  alms- 
house  are  such  that  the  whole  plant  could  be  well  devoted  to  the 
exclusive  care  of  the  insane.  It  would  then  be  possible  to  provide 
some  degree  of  classification,  and  the  present  lack  of  the  hospital 
as  to  space  for  service  departments  would  be  supplied. 

INSTITUTION  No.  24 

Physical  Conditions. — Building  for  the  insane  is  at  the  rear  of 
the  almshouse,  with  a  shed  containing  an  outdoor  toilet  in  the 
foreground.  It  is  in  a  poor  state  of  repair,  side  walls  being 
cracked,  woodwork  worn,  and  paint  generally  needed.  While 
lighting  is  by  electricity,  wiring  is  attached  to  the  surface  of  the 
walls  and  is  easily  accessible.  Despite  the  fact  that  kerosene 
lamps  are  kept  on  the  wards  for  emergency  use,  an  attendant 
was  found  smoking  in  the  ward.  Room  doors  are  locked  with 
numerous  different  kinds  of  locks,  although  most  are  secured  with 
a  small  padlock  and  a  hasp  and  staple.  There  is  little  day  space, 
except  on  dark  halls.  But  few  chairs  are  provided,  benches 
without  backs  being  substituted.  Men's  wards  are  particularly 
bare  and  desolate  in  appearance.  On  a  single  ward  there  is  one 
stationary  wash-basin,  but  elsewhere  patients  are  obliged  to  use 
the  single  bathtub  faucet  found  on  each  ward.  As  patients  eat 
breakfast  at  5.30  A.  M.,  it  appears  questionable  whether  they  all 
have  a  chance  to  wash  before  breakfast. 

Ward  dining-rooms  are  narrow,  the  two  tables  in  each  almost 
completely  filling  the  space ;  only  backless  benches  are  here  pro- 
vided. There  is  a  zinc  sink  in  each  dining-room  for  dish-washing, 
but  water  has  to  be  carried  in  a  pail  the  length  of  the  ward,  the 
bathtub  being  the  only  source  of  water  supply.  Food  service  is 

[29] 


haphazard,  patients  entering  and  leaving  dining-room  at  will. 
In  one  instance  the  attendant  had  gone  to  the  almshouse  build- 
ing for  his  own  meal,  although  patients  were  found  still  eating, 
while  thus  left  alone. 

Ventilation  is  defective  and  deodorizing  fixtures  were  seen  not 
only  in  toilets  but  in  wards.  Sewage  disposal  is  by  cesspools, 
and  one  in  use  is  but  a  few  hundred  feet  from  the  almshouse 
building.  It  should  be  added,  however,  that  plans  have  been 
made  for  more  sanitary  sewage  disposal.  There  is  a  good  exer- 
cise yard,  except  that  it  is  enclosed  by  a  high  board  fence,  com- 
pletely shutting  off  the  patients'  view,  while  it  is  undivided  for 
the  sexes.  However,  the  matter  of  exercise  fails  to  receive  proper 
attention,  many  patients  going  outdoors  but  rarely. 

Administration. — Sexes  are  poorly  separated  and  the  quiet 
patients  of  each  sex  are  allowed  to  mingle  in  going  in  and  out  of 
the  exercise  yard,  the  doors  of  the  two  quiet  wards  leading  to 
the  yard  being  left  open  much  of  the  time.  Patients  fail  to  re- 
ceive proper  personal  attention.  In  the  men's  wards  clothing 
was  found  generally  disordered,  unbuttoned,  and  in  a  few  in- 
stances torn.  When  last-mentioned  condition  existed,  there 
was  no  evidence  of  underwear.  One  male  patient  was  seen  in 
the  morning  with  clothing  unbuttoned  and  much  disordered,  and 
when  again  seen  late  in  the  afternoon  he  was  in  exactly  the  same 
condition,  being  a  stupid,  inactive  patient.  Several  men  were 
seen  barefooted ;  some  had  shoes  but  no  socks,  while  others  had 
socks  but  no  shoes.  In  general,  the  condition  of  women  was 
better  than  that  of  the  men. 

Dietary  appears  too  scanty,  practically  no  food  being  left  on 
the  tables  after  the  meal  inspected.  The  same  menu  is  served 
the  corresponding  days  each  week,  varying  only  as  the  seasons 
render  different  supplies  available.  Butter  is  served  but  once  or 
twice  a  week.  Molasses,  bread  and  coffee  are  the  staples  for 
breakfast  and  supper,  although  occasionally  a  potato,  some  oat- 
meal, or  crackers  are  added. 

The  punitive  idea  is  here  prominent;  two  women  were  found 
strapped  to  the  chair  with  a  leather  strap,  and  a  third  was  so 
strapped  to  a  toilet  chair.  It  was  readily  explained  that  in  one 
case  at  least  the  patient  was  strapped  "as  a  little  punishment"; 
it  was  added,  "You  have  to  punish  them  a  little  sometimes,  it 
does  them  good."  Later,  a  male  attendant  remarked  in  reference 

[30] 


to  restraint,  "We  use  it  simply  to  conquer  them;  it  is  to  punish 
them  a  little  when  words  are  not  enough."  The  institution  has 
several  cells  in  the  cellar  for  violent  cases,  but  none  was  occupied 
at  time  of  visit,  their  last  occupant  having  been  transferred  to  a 
State  hospital  some  weeks  prior  to  visit.  Such  cells  are  provided 
with  inside  doors  of  iron  grating,  with  heavy  wooden  doors  out- 
side. Side  walls  are  finished  in  wood.  Each  possesses  but  a 
single  high  basement  window,  so  both  light  and  air  are  deficient ; 
there  is  an  open  toilet  hopper  in  one  corner ;  they  are  heated  only 
from  cellar  passageway. 

A  visiting  physician  attends  to  the  physical  ills  of  patients, 
but  there  are  no  medical  facilities  nor  treatment  for  insanity  as 
such.  There  is  no  recreation,  and  patients  lead  a  confined  and 
monotonous  existence,  a  number  being  noted  lying  about  on  the 
floor  asleep,  there  being  no  effort  to  keep  any  occupied  except  as 
they  may  work  willingly. 

A  vicious  practice  exists  whereby  four  pauper  inmates  of  the 
almshouse  live  with  the  insane  and  one  of  the  latter  lives  in  the 
almshouse.  It  should  be  added,  however,  that  two  of  such  pau- 
pers present  mental  symptoms  and  are  to  be  shortly  committed, 
but  in  the  other  cases  they  live  as  they  do  simply  because  they 
assist  with  the  work.  There  is  also  in  the  insane  department  the 
infant  child  of  one  of  the  women  patients,  no  consideration  having 
as  yet  been  given  to  the  matter  of  its  ultimate  disposition. 

Particularly  objectionable  as  the  conditions  are  for  the  care  of 
the  insane,  it  would  be  likewise  desirable  to  remove  the  insane 
from  this  institution  for  the  reason  that  the  almshouse  is  over- 
crowded and  every  winter  it  is  necessary  to  house  almshouse 
inmates  in  the  attic,  so  good  use  could  be  made  of  the  present 
building  for  the  insane  to  relieve  this  condition. 

The  objectionable  practice  is  here  followed  of  deciding  as  to 
whether  a  patient  shall  be  committed  to  a  State  hospital  or  to  the 
county  hospital  by  the  degree  of  troublesomeness  manifested  by 
the  patient,  regardless  of  prognosis. 

INSTITUTION  No.  25 

Physical  Conditions. — A  single  story  extension  at  each  end  of 
the  almshouse  provides  accommodation  for  the  insane  of  each 
sex;  there  being  a  single  covered  connecting  corridor  to  each 
closed  by  doors  of  iron  grating  placed  at  the  entrance.  Outside 

[31] 


such  doors  hose  and  stand  pipes  are  found,  but  they  constitute 
the  only  fire  protection  for  the  insane  wards.  There  are  no  out- 
side exits  from  the  latter,  the  only  approach  being  through  the 
corridors  mentioned.  On  the  men's  side  is  a  small  basement 
dormitory  with  two  small  high  basement  windows  from  which 
there  is  but  a  single  exit  by  means  of  inside  winding,  wooden 
stairs  to  the  ward  above.  The  men's  ward  is  bare  and  cheerless, 
but  on  the  women's  side  ornamental  wall-paper  has  been  cut 
out  and  pasted  in  sections  on  the  wall,  so  as  to  give  the  effect  of 
pictures.  Windows  are  guarded  by  inside  iron  bars,  producing 
a  prison-like  effect.  Chairs  are  permanently  fastened  to  the 
floor,  and  as  a  result  patients  were  found  lying  prone  on  the  floor 
not  only  in  the  ward,  but  in  the  toilet  sections;  while  patients 
have  access  to  hot  water,  there  are  no  hot  water  safety  devices. 

Sewage  flows  untreated  into  a  swamp  about  a  mile  distant. 
Water  supply  is  limited.  Service  departments  were  found  in 
excellent  condition  and  housekeeping  generally  is  above  the  usual 
almshouse  standard.  A  particularly  good  feature,  showing  ini- 
tiative on  the  part  of  local  authorities,  is  a  home-made  refriger- 
ator, which  is  divided  into  compartments,  and  which  is  most 
satisfactory. 

There  are  no  porches  on  the  wings  for  the  insane,  although  the 
almshouse  proper  is  so  equipped.  Women's  exercise  yard  is 
unused  for  the  purpose,  but  men's  yard  is  covered  with  paths 
worn  in  the  earth  by  the  pacing  back  and  forth  of  patients.  It 
is  enclosed  on  three  sides  by  buildings  and  on  the  fourth  side  by 
a  heavy  masonry  wall  of  distinctively  prison-like  appearance. 

Administration. — One  of  the  most  serious  faults  is  the  substitu- 
tion of  close  confinement  for  personal  attention.  There  is  but  a 
single  male  attendant  and  no  women  attendants.  Women  pa- 
tients are  "looked  after"  by  the  woman  cook,  when  she  can  spare 
time  from  her  other  duties;  but  she  was  not  in  evidence  during 
visit.  As  she  sleeps  near  the  women  patients  and  the  man  at- 
tendant sleeps  in  the  male  ward,  there  is  thought  to  exist  no  neces- 
sity for  night  attendants.  Patients  are  admittedly  left  alone 
much  of  the  time.  One  result  is  that  patients'  clothing  was 
found  disordered,  in  some  instances  torn,  and  in  a  few  cases  much 
soiled ;  such  condition  being  more  marked  on  the  men's  than  on 
the  women's  side.  In  the  almshouse  proper  the  inmates  of  both 
sexes  presented  a  much  better  appearance. 

[32] 


Women  patients  never  exercise  out-of-doors,  it  being  said  "we 
can't  get  them  out"  and  their  exercise  yard  is  therefore  utilized 
for  clothes-lines.  Although  the  weather  was  favorable,  men  were 
not  out  for  exercise  on  day  of  visit.  Only  willing  workers  are 
employed,  the  majority  of  the  patients  sitting  or  lying  about  in  a 
dull,  listless  fashion.  There  are  neither  recreations  nor  religious 
services. 

Patients  eat  in  the  same  dining-room  with  the  paupers,  al- 
though at  separate  tables.  In  accordance  with  the  general  ex- 
cellence of  the  service  departments,  the  garbage  is  well  handled. 

Medical  treatment  even  for  physical  ills  is  limited.  Visiting 
physician  visits  regularly  but  once  or  twice  a  month.  He  is 
said  to  give  no  attention  to  the  insane,  except  as  indicated  by  the 
lay  superintendent.  As  it  was  expressed  in  referring  to  the  mat- 
ter, "  He  doesn't  even  know  how  many  we  have  got  in  the  Insane 
Department."  The  lay  superintendent  and  his  son  dispense 
medicines,  and  during  visit  the  latter  filled  a  bottle  with  eye-wash 
.  and  one  with  a  cough  mixture  at  the  request  of  two  pauper  in- 
mates. He  expressed  the  opinion  that  he  could  give  out  most  of 
the  medicines  needed  as  well  as  the  doctor.  A  trusty  patient 
who  has  a  room  to  himself  is  charged  with  the  duty  of  keeping  the 
ward  disinfectants. 

Institution  is  provided  with  handcuffs,  which,  however,  are 
said  to  be  but  rarely  used  except  in  transporting  patients  to  and 
from  the  institution.  Two  patients  were  found  in  seclusion  on 
occasion  of  visit.  The  opinion  was  expressed  that  seclusion  was 
a  good  practice  in  certain  cases,  for  if  patients  got  troublesome  it 
was  only  necessary  to  shut  them  up  and  allow  them  to  go  without 
a  meal  or  two,  at  the  same  time  giving  them  plenty  of  water  to 
drink,  when,  "They  will  follow  the  point  of  your  finger  around 
like  a  dog."  Despite  the  above  statement,  there  is  evidence 
that  the  local  administration  is  kindly  disposed  toward  the  pa- 
tients, and  the  attitude  indicated  appears  the  result  of  ignorance 
rather  than  intent. 

The  County  Commissioners  determine  whether  in  a  given  case 
an  insane  patient  is  to  be  committed  to  the  State  Hospital  or  the 
County  Hospital.  They  usually  consult  with  the  visiting  physi- 
cian and  the  superintendent  of  the  almshouse.  In  practice  it 
appears  that  it  is  the  latter's  opinion  which  usually  prevails,  but 
it  should  be  added  that  he  is  said  always  to  recommend  commit- 

3  [331 


ment  to  a  State  hospital  if  in  his  judgment  a  patient  can  be  im- 
proved by  treatment.  While  some  alleged  cases  of  insanity  are 
placed  in  jail  pending  commitment,  others  are  brought  to  this 
institution  and  confined  in  the  insane  ward  with  the  committed 
patients,  it  having  happened  that  patients  have  been  so  confined 
for  three  to  four  weeks  without  commitment. 

It  has  been  proposed  to  enlarge  the  capacity  of  the  insane 
ward,  the  County  supporting  a  considerable  number  of  patients 
in  the  State  hospitals,  whom  it  is  thought  can  be  supported  more 
cheaply  here,  the  question  of  expense  evidently  being  the  only 
factor  considered. 

A  deplorable  feature  of  this  institution  is  the  presence  of  nine 
children  in  the  almshouse,  it  being  remembered  that  paupers  and 
insane  eat  in  the  same  dining-room.  The  almshouse  is  over- 
crowded, especially  in  winter,  and  it  was  recently  necessary  to 
convert  part  of  the  chapel  into  bed  space,  so  good  use  could  be 
made  of  the  insane  wards  if  the  insane  were  removed,  as  would 
seem  most  desirable. 

INSTITUTION  No.  26 

Physical  Conditions. — Insane  women  occupy  the  second  floor 
of  a  wing  of  the  almshouse,  entrance  to  which  is  had  only  through 
the  almshouse  wards.  Men  insane  live  in  a  detached  building 
at  the  rear,  which  has  been  properly  condemned  by  the  State 
Committee  on  Lunacy.  This  building  has  a  central  narrow  dark 
hallway,  with  such  small  bed-rooms  on  either  side  that  beds 
occupy  most  of  the  space.  There  is  no  day  space  at  all ;  because 
of  these  and  other  conditions,  male  patients  are  no  longer  ad- 
mitted. Women's  ward  also  lacks  day  space,  owing  to  the  neces- 
sity of  using  part  of  ward  for  a  dining-room.  Both  wards  have 
inside  vertical  iron  bars  at  the  windows,  while  most  of  doors  to 
rooms  have  similar  bars  in  the  upper  half.  Wards  are  bare  and 
unattractive.  One  room  on  women's  ward  is  lined  with  tin  on 
side  walls  for  disturbed  patients.  With  but  a  single  ward  for 
each  sex,  no  classification  is  possible.  Ventilation  is  defective, 
especially  in  toilet  sections,  where  deodorizing  fixtures  were  noted. 

Service  departments  are  in  good  condition,  save  in  meat- 
cutting  room,  where  several  beef  hearts  were  seen  covered  with 
mold,  and  where  the  meat  cutting  block  was  in  an  uncleanly 
condition.  Fire  protection  is  inadequate.  Water  pressure  is 

(34) 


insufficient  to  throw  water  over  the  building,  as  it  is  obtained  from 
water  tanks  in  the  attic.  Sewage  disposal  is  unsatisfactory; 
sewage  flows  from  a  cesspool  into  trenches,  the  earth  from  which 
is  used  as  a  fertilizer. 

An  unpleasant  spectacle  was  afforded  by  a  number  of  coffins 
piled  one  on  top  of  the  other  in  a  small  storeroom  just  outside  the 
entrance  to  one  of  the  almshouse  wards,  the  door  of  which  was 
left  open  throughout  day  of  visit. 

Administration. — Male  patients  are  all  parole  patients,  and 
hence  no  attendant  is  provided.  There  is  but  one  woman  at- 
tendant, who  also  works  in  the  almshouse  department,  so  pa- 
tients are  left  alone  much  of  the  time.  Owing  to  the  lack  of 
day  space,  most  of  the  patients  were  found  in  their  rooms,  where 
they  were  idly  sitting,  only  willing  workers  being  occupied. 
Dietary  here  is  better  than  is  usual  in  almshouses.  Male  insane 
eat  with  the  male  paupers  at  the  same  table.  There  is  no  en- 
closed exercise  yard  and  such  of  the  patients  as  exercise  do  so  with 
the  paupers,  but  a  large  proportion  of  the  women  never  go  out- 
of-doors,  being  decrepit  and  unable  to  go  up  and  down  stairs 
from  the  second  floor. 

Few  patients  now  in  institution  ever  require  restraint  or 
seclusion,  but  either  may  be  used  at  the  discretion  of  the  at- 
tendant or  lay  superintendent,  the  physician  not  being  consulted. 
The  use  of  morphine  to  quiet  excited  cases  is  regulated  in  the 
same  way,  a  "practical"  nurse  from  the  almshouse  department 
administering  it  if  thought  necessary.  Institution  is  equipped 
with  leather  belt,  strait-jacket  and  leather  handcuffs,  should 
restraint  ever  be  deemed  necessary. 

It  was  formerly  the  practice  to  commit  acute  cases  of  insanity 
to  this  institution,  but  the  present  practice  is  to  commit  such 
cases  to  a  State  hospital,  the  change  in  practice  resulting  from  the 
death  of  a  patient,  while  at  home  on  parole,  from  starvation. 
It  was  said  the  patient  refused  to  eat  because  of  delusions,  and 
the  relatives  not  knowing  how  to  deal  with  the  situation  allowed 
the  patient  to  starve  to  death.  Alleged  cases  pending  commit- 
ment are  placed  either  in  jail  or  with  the  committed  insane  here. 

INSTITUTION  No.  27 

Physical  Conditions. — There  are  but  two  wards,  in  the  form  of 
narrow  halls,  the  men  living  one  floor  above  the  women,  so  no 

l35l 


classification  is  possible.  Light  and  air  are  both  deficient. 
Windows  are  but  the  width  of  two  small  old-fashioned  window- 
panes.  As  halls  furnish  most  of  the  day  space,  the  patients  re- 
main in  their  rooms  most  of  the  time,  and  the  practice  of  keeping 
the  doors  closed  renders  the  halls  darker  than  would  otherwise  be 
the  case  even  with  the  small  windows.  Both  wards  open  into 
the  almshouse  proper. 

A  dark  storage  basement  under  the  building  is  in  part  used  for 
a  tramp  room;  being  dark  and  unsanitary,  it  has  been  properly 
condemned  by  the  Committee  on  Lunacy.  General  service 
departments  are  poor.  Kitchen  in  basement  of  almshouse  has  a 
broken  concrete  floor,  is  dark  and  poorly  ventilated,  and  was 
found  in  an  uncleanly  condition,  only  pauper  help  being  here 
employed.  A  barrel  sunk  in  a  spring  is  the  only  cold  storage 
provision.  The  laundry,  situated  in  part  of  the  slaughter  house, 
is  equipped  with  wooden  tubs  only  and  hand  wringers.  The 
clothes  are  dried  on  out-of-door  lines  or  in  the  attic,  and  are  ironed 
in  the  almshouse  basement.  The  boiler  room  for  heating  is 
situated  below  the  surface  of  the  ground,  so  that  the  ashes  have  to 
be  carried  by  hand  up  a  flight  of  steps. 

Sewage  disposal  is  unsanitary.  There  are  two  cesspools,  each 
about  200  feet  from  the  building.  At  times  these  overflow  and 
formerly  would  then  flow  into  a  neighboring  creek,  but  owing  to 
objection  on  the  part  of  the  State  Board  of  Health,  when  over- 
flow occurs  it  is  now  carried  by  ditches  to  waste  land  about  one 
quarter  of  a  mile  distant. 

Fire  protection  is  extremely  poor.  The  only  water  pressure 
is  obtained  from  a  small  attic  reservoir,  with  a  capacity  of  150 
barrels;  there  is  a  second  such  reservoir  which  has  never  been 
used  owing  to  the  expense  of  making  connections.  A  single 
screw  nozle  faucet  for  garden  hose  is  placed  outside,  some  dis- 
tance from  the  building,  and  this  furnishes  the  only  means  of 
fighting  fire,  there  being  no  inside  provisions  whatever.  There 
are  two  unenclosed  outside  iron  fire-escapes.  There  is  a  single 
inside  wooden  stairway  at  the  junction  of  the  building  for  insane 
with  the  almshouse  proper,  there  being  no  outside  exits  at  other 
end  of  building,  except  through  windows,  to  the  fire-escape.  A 
recent  addition  supplied  by  the  steward's  initiative  is  an  outside 
wooden  stairway  to  the  second  floor  at  almshouse  end.  That 
the  fire  risk  from  lack  of  water  has  been  appreciated  is  evinced 

[36] 


by  the  statement  that  plans  have  been  considered  for  connection 
with  the  water  mains  of  the  neighboring  city,  which  pass  directly 
in  front  of  the  property.  As  yet,  however,  no  action  has  been 
taken  owing  to  the  expense  involved. 

The  wards  are  provided  with  outside  iron-barred  window 
guards,  and  in  so-called  "strong  rooms"  such  guards  are  also 
placed  inside  the  windows.  There  is  a  short  hall  on  each  ward, 
at  one  end  of  which  is  the  dining-room  and  at  the  other  end  the 
toilet  section.  The  toilet  facilities  are  all  in  one  open  room. 
There  are  no  hot  water  safety  devices,  although  patients  have  free 
access  to  faucets.  The  hot  water  supply  is  limited,  however, 
being  obtained  only  from  a  heater  on  the  kitchen  stove.  It 
was  admitted  that  the  supply  frequently  becomes  exhausted 
before  bathing  is  completed.  Plumbing  is  old,  worn,  and  much 
of  it  is  concealed  in  the  walls.  It  was  said  that  on  one  occasion 
it  was  necessary  to  tear  up  an  entire  floor  in  order  to  make  neces- 
sary plumbing  repairs.  Each  so-called  "strong  room,"  aside 
from  extra  window  guards,  is  provided  with  an  extra  door  of  open 
iron  grating  inside  the  wooden  door.  Ore  such  room  has  side 
walls  lined  with  tin,  a  disturbed  patient  having  destroyed  the 
plaster.  Benches  and  chairs  are  both  provided,  the  quiet  stupid 
patients  being  kept  on  the  former,  ranged  along  the  side  walls. 
As  it  was  expressed  in  pointing  out  one  such  patient,  "She  usually 
stays  right  there  where  she  is  put  all  day  long." 

Exercise  yards  are  enclosed  by  a  high,  whitewashed  board  fence, 
in  part  surmounted  by  barbed  wire. 

Administration. — Food  service  is  very  poor,  it  being  necessary 
to  carry  all  food  by  hand  from  the  almshouse  through  the  length 
of  the  wards  to  the  dining-rooms.  The  food  served  is  the  same 
as  for  paupers,  and  it  lacks  variety.  The  same  meals  are  served 
on  corresponding  days  each  week,  except  only  as  the  seasons 
change.  Bread,  butter,  molasses,  and  coffee  are  served  for  prac- 
tically every  breakfast  and  supper.  For  the  latter  meal,  how- 
ever, an  onion,  tomato,  or  apple  is  occasionally  added.  Each 
patient  receives  a  glassful  of  butter  weekly,  the  whole  amount 
being  left  in  charge  of  the  individual  patient.  It  is  said  that  some 
consume  their  allotment  within  a  day  or  so,  while  others,  more 
economically  inclined,  keep  the  butter  in  their  rooms  and  make 
it  last  the  entire  week.  Patients  are  also  allowed  to  take  meat 
from  the  table  to  their  rooms  after  the  noonday  meal,  so  that 

[371 


they  can  save  it  for  supper.  A  woman  patient  was  pointed  out  as 
being  able  to  go  for  long  periods  without  food,  it  being  said  that 
she  had  gone  as  long  as  sixteen  days  without  apparent  injury. 
It  was  added,  with  a  smile,  "She  soon  makes  up  for  lost  time  when 
she  again  starts  to  eat." 

Patients  can  necessarily  receive  but  little  personal  attention, 
the  only  attendants  being  one  married  couple.  In  lieu  of  a  night 
attendant,  a  colored  pauper  is  used  as  an  outside  night  watch- 
man. He  is  not  allowed  to  enter  the  buildings.  The  male 
attendant  was  formerly  a  farmer,  and  neither  he  nor  his  wife 
ever  had  previous  experience  with  insane.  It  should  be  added 
that  they  both  appear  to  be  doing  their  duty  as  well  as  possible 
under  defective  conditions,  and  according  to  their  lights,  this 
being  evinced  by  the  good  housekeeping  and  the  unusually  good 
condition  of  patients'  clothing. 

The  practice  exists  of  keeping  untidy  patients  in  the  toilet 
sections,  and  on  day  of  visit  four  male  patients  were  found  there 
seated  on  a  bench  and  restrained,  it  being  necessary  to  leave  them 
alone  most  of  the  time,  as  the  single  attendant  performed  his 
duties  elsewhere.  One  such  patient  was  said  to  be  constantly 
restrained;  two  of  them  were  fastened  to  the  bench  by  leather 
straps  about  the  waist,  and  one  had  his  hands  secured  by  a  leather 
muff.  The  latter  also  had  a  wire  screen  cage  over  his  head  rest- 
ing on  his  shoulders,  it  being  explained  that  even  when  restrained 
he  tore  his  clothing  with  his  teeth.  These  patients,  together  with 
an  unrestrained  stupid  patient  sitting  with  them,  were  bare- 
footed, their  feet  resting  on  the  concrete  floor.  While  it  was  said 
they  were  not  used  in  the  institution,  steel  handcuffs  are  used  in 
transporting  patients  either  to  or  from  it.  A  disturbed  patient 
who  died  during  the  past  year  was,  in  the  opinion  of  the  local 
authorities,  "worried  to  death."  This  patient  was  so  violently 
disturbed  that  even  when  handcuffed  with  his  hands  behind  his 
back,  or  beneath  his  knees,  and  being  meanwhile  strapped  to  the 
bed,  he  could  free  himself.  On  one  occasion  after  being  locked  in 
his  room  when  restrained  in  the  manner  described,  he  not  only 
freed  himself  but  tore  the  screen  from  the  radiator  and  sustained 
severe  burns,  which  appear  to  have  been  at  least  a  complicating 
factor  in  causing  death.  It  was  stated  that  even  when  this 
patient  was  in  one  of  his  wildest  moods,  he  could  be  quieted  when 
the  steward  talked  to  him,  as  it  was  expressed,  "in  a  sensible 

[38] 


manner."  At  such  times  the  patient  declared  he  was  not  insane 
but  simply  was  unable  to  control  himself.  The  facts  as  given 
would  indicate  that  had  patient  received  proper  personal  at- 
tention, and  had  proper  medical  treatment  been  instituted  for 
the  relief  of  his  mental  condition,  the  case  would  have  had  a  very 
different  termination,  as  the  symptoms  described  indicate  that 
he  was  suffering  from  a  recoverable  form  of  insanity. 

The  visiting  physician  regularly  calls  but  three  times  a  week,  and 
although  it  was  admitted  that  the  State  Committee  on  Lunacy 
had  spoken  about  the  matter,  no  clinical  records  are  kept.  There 
are,  of  course,  no  medical  facilities  or  treatment  for  mental  disease. 

The  separation  of  the  sexes  is  poor,  on  which  account  the  pres- 
ence of  several  erotic  girl  imbeciles  constitutes  a  menace. 

Owing  to  the  fact  that  the  almshouse  only  is  provided  with 
dormitories,  and  the  building  for  the  insane  only  with  single 
rooms,  the  custom  prevails  of  caring  for  certain  of  the  insane  in 
the  almshouse  proper,  and  for  certain  of  the  pauper  inmates  of 
the  almshouse  with  the  insane. 

Alleged  cases  of  insanity  if  quiet  are  cared  for  in  the  almshouse, 
but  if  disturbed  are  placed  in  the  "strong  rooms"  of  the  insane 
department.  Commitment  is  by  the  Commission  process,  the 
Commission  recommending  whether  commitment  shall  be  to  a 
State  hospital  or  the  county  institution.  It  was  freely  admitted 
that  the  issue  was  determined  by  the  degree  of  troublesomeness 
manifested  by  the  patient,  or  should  the  patient  belong  to  one 
of  the  "better  families,"  the  recommendation  is  always  for  com- 
mitment to  a  State  hospital. 

The  almshouse  is  utilized  to  capacity,  is  overcrowded  every 
winter,  and  it  could  well  use  the  building  now  occupied  by  the 
insane,  especially  as  they  would  supplement  one  another  as  re- 
gards single  rooms  and  dormitories.  There  thus  appears  an 
added  reason,  apart  from  the  deplorable  conditions,  why  the  in- 
sane should  be  removed  from  this  institution  at  the  earliest  pos- 
sible moment. 

INSTITUTION  No.  28 

Physical  Conditions. — An  extension  from  either  end  of  the 
almshouse  provides  a  single  story  ward  for  the  insane  of  each  sex, 
each  ward  being  connected  with  the  almshouse  proper  by  a  cov- 
ered corridor,  at  the  entrance  to  which  are  doors  of  heavy  iron 

l39l 


grating.  A  similar  iron  door  shuts  off  a  short  hall  on  which  single 
rooms  open,  such  door  being  regarded  as  necessary  when  patients 
are  secluded  in  their  rooms,  although  the  latter  are  locked. 
There  is  a  single  day  room  on  each  side  where  all  types  of  cases 
mingle.  Wards  are  bare  and  in  some  places  plaster  has  fallen, 
although  on  day  of  visit  repairs  were  in  progress  where  such 
damage  was  most  extensive.  Toilet  facilities  are  fairly  satis- 
factory, except  that  the  single  bathtub  for  each  sex  is  placed  in  a 
small  room,  which,  with  but  a  single  small  window,  is  dark  and 
poorly  ventilated,  while  no  hot  water  safety  devices  are  provided. 

Single  rooms  have  no  lights  and  are  locked  at  night.  Several 
such  rooms,  used  for  seclusion,  have  adjoining  toilets  which  have 
no  opening  aside  from  the  door. 

There  is  an  exercise  yard  for  each  sex,  enclosed  by  a  high  iron 
picket  fence;  neither  has  any  shelter.  Although  the  almshouse 
has  porches,  there  are  none  for  the  insane. 

Only  fire  protection  is  provided  by  a  hose  and  standpipe  out- 
side the  iron  doors*^at  the  entrance  to  the  corridors  connecting 
the  almshouse  with  the  insane  wards.  The  only  outside  exits 
from  the  latter  are  into  the  exercise  yards,  and  there  is  no  gate 
in  the  surrounding  iron  fence.  But  part  of  the  steam  radiators 
are  protected.  Sewage  disposal  is  most  unsanitary;  sewage 
flows  untreated  into  a  small  creek  about  200  yards  from  the  front 
of  the  building;  when  seen,  the  creek  had  little  water,  sewage 
was  stagnant,  and  there  was  considerable  odor. 

Administration. — Patients  receive  little  personal  attention,  as 
would  be  expected  under  the  conditions,  there  being  but  a  single 
male  and  a  single  female  attendant.  The  former  is  termed  assistant 
superintendent,  works  on  the  farm,  and  admittedly  spends  little 
time  in  the  wards,  which  are  left  in  charge  of  a  trusty  patient  in 
his  absence.  The  woman  attendant  spends  the  greater  portion 
of  her  time  in  the  sick  ward  of  the  almshouse,  being  the  only 
woman  employee  aside  from  the  matron  and  cook.  The  insane 
patients  are,  therefore,  left  to  their  own  devices  much  of  the  time. 
There  is  no  night  employee — not  even  a  watchman. 

The  housekeeping  is  generally  poor — dust  and  cobwebs  being 
much  in  evidence.  Toilet  sections  were  in  particular  disorder. 
A  number  of  beds  were  seen  in  the  afternoon  just  as  they  had  been 
left  by  patients  on  arising  in  the  morning.  Patients  are  allowed 
to  collect  worthless  trinkets  and  rubbish  in  their  rooms,  and  in 

[40] 


one  room  a  large  piece  of  broken  glass  was  noted.  A  patient 
was  found  smoking  in  the  ward  without  exciting  comment. 

Although  clothing  is  of  fair  quality,  it  is  poorly  cared  for — 
in  the  majority  of  cases  buttons  were  found  off  and  clothing 
open;  much  of  clothing  was  soiled  and  some  torn.  One  young 
girl's  dress  was  so  torn  as  to  expose  her  person.  Many  patients 
were  seen  without  shoestrings,  and  a  number  of  both  sexes  seen 
barefooted;  in  the  latter  instances,  from  the  appearance  of  the 
feet,  patients  had  not  worn  shoes  and  stockings  for  a  long  time; 
it  would  have  been  impossible  for  one  man  to  have  done  so, 
because  of  the  extreme  length  of  his  toe-nails. 

Sufficient  food  is  apparently  supplied,  but  there  is  little  va- 
riety. Meat  is  served  but  three  or  four  times  a  week. 

Only  willing  workers  are  occupied,  and  they  constitute  a  com- 
paratively small  percentage  of  the  total  number.  Idle  patients 
have  no  regular  exercise,  and  on  day  of  visit,  although  weather 
was  favorable,  no  men  were  out.  On  the  women's  side,  however, 
the  door  from  the  ward  to  the  exercise  yard  stood  open,  and  some 
of  the  women  were  found  in  the  yard,  one  lying  prone  on  her 
back  with  the  sun  shining  full  in  her  face,  without  anyone  giving 
heed.  Several  of  the  women  in  the  yard  were  talking  loudly, 
while  on  the  other  side  of  the  open  iron  picket  fence  children 
from  the  almshouse  were  playing. 

There  are  no  recreations.  Only  occasionally  do  a  few  of  the 
insane  attend  religious  services  in  the  almshouse,  and  for  the 
most  part  patients  lead  a  mechanical  and  monotonous  existence. 

With  such  a  limited  amount  of  personal  attention,  restraint 
and  seclusion  are  both  necessarily  used;  the  forms  of  restraint 
used  include  leather  wrist  cuffs  and  muffs  and  the  strait-jacket. 
One  woman  patient  is  constantly  restrained  with  leather  muffs, 
so  she  has  to  be  fed  and  undressed  by  others.  It  was  ex- 
plained that  "She  tears  her  clothing  and  is  very  bad."  When 
patient  was  questioned,  she  said,  "  I  would  be  good  if  they  would 
take  this  off,"  indicating  the  muffs.  As  to  seclusion,  the  at- 
tendant remarked  that  it  was  rarely  necessary  to  keep  them 
locked  up  more  than  half  a  day,  as  "That  is  usually  enough  to 
tone  them  down."  A  paralyzed  man  was  found  locked  in  his 
room  with  both  the  bed  and  floor  in  a  foul  condition,  but  the  door 
was  again  locked,  the  condition  found  causing  no  comment. 

There  are  no  special  medical  facilities  except  that  a  seriously 

[41] 


sick  patient  is  removed  to  the  sick  ward  in  the  almshouse,  which 
is  an  ordinary  dormitory  set  apart  for  the  purpose.  The  visiting 
physician  calls  regularly  but  once  a  week,  and  that  patients  do 
not  receive  sufficient  medical  attention  is  evinced  by  the  condition 
in  which  a  stupid  male  patient  was  found.  He  had  a  large  abscess 
on  the  side  of  his  neck,  evidently  of  some  duration,  as  the  pus  had 
burrowed  a  considerable  distance  through  the  tissues.  Although 
the  superintendent  inquired  of  other  patients  how  long  the  condi- 
tion had  existed,  nobody  was  found  who  knew  anything  about  it. 

An  unfortunate  feature  of  the  situation  is  that  the  visiting 
physician  believes  that  acute  cases  of  insanity  can  be  cared  for 
here  without  difficulty,  his  idea  of  the  treatment  of  mental  disease 
being  summed  up  in  the  phrase,  "Build  them  up." 

Alleged  cases  of  insanity  are  sent  here  pending  commitment, 
and  they  often  remain  several  weeks,  no  distinction  being  made 
between  them  and  the  committed  cases.  One  male  case  at  pres- 
ent in  the  institution  has  been  here  for  several  months,  the  ex- 
amining physicians  having  refused  to  commit  him,  and  his  rela- 
tives having  refused  to  allow  him  to  return  home. 

An  unfortunate  tendency  was  observed  here  as  in  several  other 
county  institutions  in  reference  to  general  visitors.  On  day  of 
visit,  there  were  three  parties  of  general  visitors,  whose  interest 
in  seeing  the  insane  was  quite  evidently  one  of  morbid  curiosity, 
as  they  did  not  fail  to  make  audible  comments  about  the  women 
patients  as  they  stared  at  the  latter  through  the  iron  fence  sur- 
rounding the  exercise  yard. 

All  positions  in  both  insane  department  and  almshouse  are 
regarded  as  political  assets,  even  the  male  attendant  receiving  his 
appointment  as  a  reward  for  political  service.  The  superin- 
tendent is  a  former  farmer,  who  frankly  admits  he  knows  nothing 
about  the  insane. 

Were  the  insane  removed  from  this  institution,  as  existing 
conditions  render  most  advisable,  the  two  wards  could  be  used  to 
advantage  by  the  almshouse,  where  every  winter  there  exists  much 
overcrowding. 

INSTITUTION  No.  29 

Physical  Conditions. — The  institution  is  inaccessible,  except 
by  private  conveyance;  it  is  located  six  miles  from  the  nearest 
railroad,  over  poor  highways.  The  almshouse  adjoins  a  recently 
erected,  substantial,  fireproof  building  for  the  insane  which  has 

[42] 


but  a  single  ward  for  each  sex,  men  occupying  the  first  floor  and 
women  the  second.  A  prison  effect  is  produced  by  heavy  iron 
bars  at  the  windows  and  iron  grating  doors  outside  wooden  ones 
at  the  outside  entrance.  Toilet  facilities  are  modern,  but  there 
is  an  insufficient  number  of  wash-basins.  Dormitories  are  excel- 
lent, but  there  is  only  one,  single  room  for  each  sex.  There  is  a 
lack  of  day  room  space,  considering  the  number  of  patients  cared 
for.  As  a  result  of  the  impossibility  of  classification  and  the 
close  physical  contact,  two  discolored  eyes  were  noted  among  the 
women  patients.  Some  overcrowding  was  evident,  and  a  few 
mattresses  on  the  floor  indicated  lack  of  sufficient  bed  space. 

Service  departments  are  in  basement,  where  the  dining-room 
also  is  located.  Decrepit  patients  eat  in  the  ward,  and  two  cases 
were  noted  of  patients  eating  from  the  top  of  a  screened  radiator. 
Food  is  apparently  satisfactory. 

Service  departments  are  generally  well  conducted,  particularly 
the  outside  departments,  under  the  direction  of  the  almshouse 
steward.  Farm  work  especially  appears  to  be  done  in  an  effi- 
cient manner. 

There  is  no  provision  for  fire  fighting,  except  water  lines,  the 
pressure  in  which  is  obtained  only  from  tanks  in  the  neighboring 
almshouse  attic,  and  which  are  therefore  unreliable  and  insuf- 
ficient. Dependence  is  admittedly  placed  on  fireproof  construc- 
tion of  building,  although  it  has  the  usual  interior  wooden  trim. 
Kerosene  is  kept  in  the  basement. 

Raw  sewage  flows  into  a  neighboring  creek,  but  plans  have 
been  formulated  for  two  settling  tanks. 

Exercise  yard  is  enclosed  with  wire  netting,  but  exercise  is 
irregular,  and  is  only  possible  when  resident  physician  is  present 
to  act  as  an  attendant,  owing  to  the  limited  number  of  attendants 
employed.  In  his  absence  on  day  of  visit  patients  were  not  out 
for  exercise. 

A  so-called  "cell"  in  the  basement  is  used  for  seclusion.  It 
is  an  unfurnished  room  with  a  single  high  basement  window,  so 
light  and  air  are  deficient;  it  has  a  concrete  floor  with  a  drain  in 
the  center,  in  lieu  of  toilet  facilities,  and  is  provided  with  a  heavy 
wooden  door  of  double  timbers.  While  patients  in  seclusion  are 
taken  to  the  toilet  during  the  day,  they  are  not  at  night,  the  room 
being  flushed  with  a  hose  in  the  morning.  It  had  been  vacated 
day  prior  to  visit  and  an  odor  was  still  perceptible. 

[43] 


While  the  main  almshouse  building  was  fairly  acceptable, 
two  detached  buildings  for  male  paupers  were  in  a  dilapidated 
condition;  one  has  been  condemned  by  State  authorities,  and 
it  would  appear  that  both  should  be.  Plans  have  been  formu- 
lated for  a  building  to  replace  the  condemned  almshouse  build- 
ing, but  such  necessity  would  not  exist  could  the  insane  be  re- 
moved from  this  institution,  as  the  lack  of  facilities,  especially 
regrettable  in  a  new  building,  renders  desirable. 

Administration. — Existing  conditions  are  held  responsible  for 
the  free  use  of  restraint,  although  they  do  not  seem  to  offer  an 
excuse  for  the  forms  employed.  On  day  of  visit  a  man  was  re- 
strained with  steel  handcuffs,  fastened  tightly  about  his  wrists, 
because,  as  it  was  explained,  "If  they  were  loose,  he  would  free 
himself."  Both  wrists  were  abraded,  evidently  as  a  result  of  his 
struggles.  He  repeatedly  asked  to  be  freed,  and  when  he  was 
asked  why  he  did  not  conduct  himself  properly,  he  inquired  in 
turn  how  could  he  with  the  handcuffs  on.  When  seen,  he  was 
sitting  on  a  chair  talking  in  a  moderate  tone,  and  showing  no 
great  unrest.  Comment  being  made  on  the  form  of  the  restraint 
when  the  ward  was  first  visited,  it  was  noted  when  passing  through 
the  ward  later  that  the  handcuffs  had  been  removed.  The 
patient  was  moving  rather  restlessly  about,  but  was  smiling  and 
less  talkative  than  when  first  seen,  making  no  trouble  whatever. 
He  was  said  to  be  a  recurrent  maniacal  case  and  able  to  tell 
the  day  before  when  an  attack  is  impending.  He  will  then 
spend  considerable  time  dashing  cold  water  over  his  head,  but 
such  efforts  on  the  part  of  the  patient  do  not  appear  to  have  ever 
caused  his  caretakers  to  think  of  using  showers,  wet  packs,  or 
such  forms  of  hydrotherapy  as  are  possible  without  special  ap- 
paratus. The  forms  of  restraint,  aside  from  steel  handcuffs, 
include  the  strait-jacket,  leather  cuffs  and  anklets,  the  latter 
being  exhibited  in  a  broken  condition,  a  male  patient  having 
succeeded  in  freeing  himself  from  them. 

A  fair  proportion  of  the  patients  are  occupied,  but  occupation 
is  unregulated  except  in  accord  with  the  demands  of  the  Board 
of  Directors,  who  are  said  to  be  constantly  complaining  that  an 
insufficient  amount  of  work  is  obtained  from  the  patients. 

Medical  facilities  are  limited,  even  for  the  treatment  of  physi- 
cal disease,  which  is  admittedly  the  only  medical  treatment. 
The  resident  physician  was  recently  appointed,  after  answering  an 

[44] 


advertisement,  and  so  far  as  known  has  never  had  any  experience 
with  the  insane.  He  is  allowed  to  engage  in  general  practice. 
Nobody  knew  the  cause  of  his  absence  on  day  of  visit,  or  when  he 
was  apt  to  return.  A  single  tubercular  patient  mingles  with  the 
others  without  restriction. 

There  is  a  general  atmosphere  of  depression  pervading  the 
institution,  and  the  punitive  idea  prevails.  Attendants  were 
heard  ordering  patients  in  a  most  peremptory  manner  to  perform 
various  tasks. 

Business  affairs  and  the  matter  of  supplies  are  in  charge  of  the 
almshouse  superintendent.  The  latter  is  of  progressive  ten- 
dencies, and  has  made  numerous  changes  during  his  tenure  of 
office  tending  to  a  more  business-like  administration. 

INSTITUTION  No.  30 

Physical  Conditions. — Main  building  for  insane  is  of  an  old 
type,  but  fairly  satisfactory.  A  detached  building,  however, 
used  by  untidy  patients,  is  dilapidated  and  unfit  for  occupancy. 
The  neighboring  almshouse  building  is  of  recent  construction, 
and  is  much  superior  to  any  other  building  of  the  entire  plant. 
Aside  from  wards  in  detached  building,  insane  wards  are  well 
furnished  and  comfortable.  Toilet  facilities,  however,  are  in- 
sufficient in  number  and  in  part  of  an  old,  antiquated  type. 
Steam  radiators  are  but  partly  protected,  although  work  is  in 
progress  to  screen  them  all,  following  recommendation  of  State 
Committee  on  Lunacy  made  nearly  two  years  ago. 

Kitchen  is  too  small,  but  is  well  equipped.  A  new  building  is 
in  process  of  erection  to  replace  present  unsatisfactory  laundry; 
it  will  likewise  provide  an  amusement  hall,  the  present  one  on  the 
fourth  floor  furnishing  an  undue  fire  risk.  Cold  storage  facilities 
are  inadequate,  but  otherwise,  except  as  noted,  service  depart- 
ments are  satisfactory. 

Fire  protection  is  fair,  but  no  fire  drills  are  held,  being  regarded 
as  undesirable. 

Exercise  yard  is  enclosed  by  a  high  iron  picket  fence,  and 
divided  by  a  brick  wall  for  the  sexes.  However,  the  practice 
of  allowing  patients  to  exercise  on  the  open  lawn  is  increasing. 

There  is  a  modern  hydrotherapeutic  plant,  including  continu- 
ous baths,  but  it  is  poorly  located.  Disturbed  patients,  for  whom 
such  treatment  is  mostly  indicated,  are  kept  on  the  floor  above 

[45] 


and  it  is  necessary  not  only  to  bring  them  downstairs  but  through 
a  hallway  and  the  main  dining-room  to  receive  hydrotherapeutic 
treatment,  so  its  use  must  necessarily  be  restricted. 

While  two  wards  are  set  apart  for  the  reception  of  new  cases, 
neither  have  any  special  facilities.  There  is  no  provision  for  the 
isolation  of  tubercular  cases,  except  that  advanced  cases  are  kept 
in  single  rooms. 

Administration. — Formerly  the  superintendent  of  the  alms- 
house  was  the  executive  head  of  the  whole  plant,  but  in  recent 
months  a  change  was  made  whereby  the  resident  physician  be- 
came chief  executive  of  the  insane  hospital;  he  has  no  voice  as 
to  supplies,  however,  other  than  strictly  medical  ones,  and  cloth- 
ing, food,  etc.,  are  not  regarded  in  the  latter  category.  An  even 
more  serious  administrative  defect  is  that  while  the  physician  may 
indicate  which  patients  may  go  outdoors  for  work,  they  are  under 
the  direction  of  the  almshouse  superintendent  as  soon  as  they 
leave  the  ward,  so  the  physician  has  no  voice  as  to  the  tasks 
assigned  individual  patients,  and  there  is  considerable  evidence 
that  the  needs  of  the  work  are  considered  before  the  needs  of  the 
patients.  There  are  no  occupational  classes. 

A  good  result  following  the  administrative  change  is  the  re- 
duction of  restraint  and  seclusion.  On  day  of  visit  but  a  single 
patient  was  restrained,  being  a  homicidal  woman  who  had  one 
hand  only,  secured  by  a  leather  cuff  and  fastened  to  a  leather  belt 
about  her  waist. 

There  is  an  insufficient  number  of  attendants  and  but  a  single 
graduate  nurse  to  care  for  the  sick,  not  only  in  the  insane  hospi- 
tal but  in  the  almshouse.  It  is  said,  however,  that  a  training 
school  for  nurses  is  planned.  There  are  but  two  physicians  to 
care  for  over  500  insane  patients  and  the  sick  in  the  almshouse, 
but  it  is  said  another  physician  is  to  be  added  to  the  staff.  There 
is  no  provision  for  dental  work. 

There  is  no  reason  to  doubt  but  that  patients'  material  comfort 
receives  proper  attention,  although  the  care  given  is  but  custo- 
dial. There  is  a  lack  of  facilities,  not  only  for  the  treatment  of 
acute  insanity,  but  for  the  treatment  of  physical  ills.  There  is  no 
pathologic  work  and  but  a  meager  amount  of  clinical  laboratory 
work,  the  facilities  for  which  are  limited  and  crude.  Medical 
records  are  poor,  but  improvements  in  this  respect  are  planned. 

Defective  discipline  prevails;  an  attendant  was  found  smoking 
in  the  ward  without  exciting  comment. 

[46] 


Business  methods  are  defective  and  do  not  provide  for  the 
rejection  of  unsatisfactory  deliveries  of  supplies.  There  is  in- 
sufficient checking  of  the  latter,  so  that  the  interests  of  the  in- 
stitution are  not  sufficiently  safeguarded. 

There  is  evidence  that  political  influences  have  frequently 
asserted  themselves  in  regard  to  hospital  matters,  especially  con- 
cerning appointments  to  the  higher  positions. 

In  view  of  the  fact  that  the  excellent  almshouse  building  has 
never  yet  been  occupied  to  capacity,  while  part  of  the  insane 
are  occupying  a  building  unfit  for  habitation,  it  would  seem  de- 
sirable that  the  whole  plant  be  converted  to  the  use  of  the  insane 
alone.  Could  such  a  plan  be  adopted,  this  institution  would 
form  the  nucleus  of  a  good  State  hospital,  material  facilities  being 
in  the  main  satisfactory.  The  comparatively  large  acreage  here 
available  would  permit  of  future  development. 

INSTITUTION  No.  31 

Physical  Conditions. — The  insane  occupy  two  buildings,  situ- 
ated between  the  main  almshouse  building  on  one  side  and  the 
almshouse  hospital  building  on  the  other,  all  being  connected  by 
covered  passageways.  One  building  for  the  insane  is  of  com- 
paratively recent  construction  and  fairly  satisfactory;  it  lacks 
sufficient  toilet  and  bath  facilities,  however,  and  some  of  the 
plumbing  is  placed  so  low  as  to  afford  opportunity  for  suicidal 
attempts.  Heating  facilities  are  insufficient.  In  the  old  build- 
ing the  floors  are  badly  worn,  walls  are  smoked,  cracked  and 
broken,  woodwork  is  worn,  and  paint  is  generally  needed.  The 
ceilings  are  low,  there  are  numerous  dark,  narrow  passageways, 
and  its  dilapidated  condition  renders  it  unfit  for  human  occu- 
pancy. Some  of  the  patients'  rooms  in  this  building  have  iron 
grating  doors  inside  of  solid  wooden  ones,  and  have,  in  addition 
to  the  usual  outside  iron-barred  window  guards,  heavy  wire 
screens  placed  inside  the  windows.  On  one  of  the  women's 
wards  a  heavy  iron-barred  partition  extends  from  the  floor  to  the 
ceiling,  shutting  off  one  end  of  the  hall,  so  that  patients  cannot 
reach  the  windows.  Part  of  toilet  sections  have  wooden  floors, 
and  toilet  accommodations  are  not  only  insufficient  but  anti- 
quated, worn,  and  unsanitary.  Numerous  small,  dark  closets 
are  found  and,  in  general,  light  and  ventilation  are  extremely 
poor.  Benches  provide  the  only  seating  facilities,  and  being 

[47] 


devoid  of  any  decorative  features,  the  interior  of  the  old  build- 
ing presents  a  most  dismal  and  desolate  appearance. 

The  dining-rooms  in  the  old  building  are  particularly  objec- 
tionable, there  being  no  service  facilities.  Food  appears  satis- 
factory, although  a  stereotyped  menu  is  repeated  weekly. 

Lighting  is  by  electricity,  but  in  the  old  building  wiring  is 
attached  to  the  surface  of  walls  and  ceilings,  and  is  easily  acces- 
sible to  patients.  Although  steam  radiators  are  unprotected,  it 
was  said  a  contract  has  been  let  to  install  protecting  screens. 

Sewage  flows  untreated  into  a  creek  about  500  feet  from  the 
rear  of  the  buildings.  Fire  protection  is  defective,  especially  in 
the  old  building.  Water  pressure  is  variable  and  is  not  always 
sufficient  to  reach  the  upper  floors. 

Exercise  yard  is  below  the  ground  level  on  one  side,  being  dug 
out  of  a  hillside,  so  that  it  is  at  the  ground-floor  level  of  the  ad- 
joining building,  which  stands  on  the  slope.  The  yard  is  sur- 
rounded by  whitewashed  stone  walls  and  is  divided  in  the  middle 
for  the  sexes.  Patients  exercising  here  can  be  heard  easily  on 
the  street  in  front,  the  institution  being  located  in  a  residential 
suburb,  and  it  is  admitted  that  neighbors  occasionally  complain. 

The  outside  departments  belong  to  the  almshouse  and  patients 
working  in  them  are  under  the  direction  of  the  almshouse  su- 
perintendent. The  rear  yards  and  those  about  the  farm  build- 
ings were  found  littered  with  considerable  rubbish  and  flies  were 
numerous.  But  a  short  distance  from  the  springhouse,  where 
milk  is  handled,  at  a  point  about  500  yards  from  the  patients' 
buildings,  is  a  frame  piggery  found  in  a  most  unsanitary  state, 
rubbish  and  garbage  being  scattered  over  the  ground  about  it. 
It  was  remarked:  "This  condition  probably  accounts  for  the 
many  flies  throughout  the  institution." 

The  new  building  contains  practically  all  dormitories  and  the 
old  one  practically  all  single  rooms,  hence  classification  is  dif- 
ficult. The  official  capacity  has  been  increased  as  patients  have 
increased,  although  without  additional  accommodations,  and  a 
serious  degree  of  overcrowding  exists,  as  is  shown  by  local  calcu- 
lations, which,  including  both  bedroom  space  and  dayroom  space, 
give  but  350  cubic  feet  of  air  space  per  patient. 

There  is  no  hydrotherapeutic  apparatus  and  no  special  medical 
facilities,  aside  from  a  small,  but  well-equipped  clinical  labora- 
tory, established  by  a  former  physician,  but  the  present  resident 

[48] 


physician  has  no  opportunity  to  use  it,  having  no  assistant,  and 
being  charged  with  the  care  of  over  300  insane  patients,  besides 
the  physically  sick  in  the  almshouse. 

There  is  a  detached  building  for  contagious  diseases  which 
stands  idle  most  of  the  time.  In  view  of  the  fact  that  tubercular 
cases  have  to  be  kept  with  other  patients,  it  would  seem  that 
such  a  building  should  be  utilized  for  their  care.  New  tubercu- 
lar cases  not  infrequently  develop  in  the  wards,  in  the  majority 
of  instances  the  disease  resulting  fatally,  and  of  the  total  number 
of  deaths  occurring  the  last  hospital  year,  27  per  cent,  were  from 
tuberculosis.  It  was  said  that  the  State  Committee  on  Lunacy 
directed  that  the  insane  hospital  should  use  the  above-mentioned 
building,  but  the  Board  of  Directors  adopted  a  resolution  oppos- 
ing such  suggestion  and  no  further  action  has  been  taken.  It 
was  said  that  such  building  when  erected  was  approved  by  the 
State  Board  of  Charities  with  the  understanding  that  it  should  be 
used  only  for  cases  of  contagious  diseases  occurring  in  the  in- 
stitution, but  the  Board  of  Poor  Directors  have  used  it  only  for 
cases  of  contagious  disease  occurring  outside  the  institution. 

The  almshouse  hospital  building  is  much  less  objectionable 
than  the  old  building  for  the  insane,  and  hence  the  practice  of 
caring  for  occasional  sick  insane  patients  in  it  is  less  inhumane 
than  might  appear  at  first  sight. 

Administration. — There  is  reason  to  believe  that  the  custodial 
care  given  is  as  good  as  could  be  expected  under  the  conditions, 
but  it  is,  of  course,  custodial  care  only.  Patients'  clothing  is 
above  the  average  and  they  apparently  receive  as  much  personal 
attention  as  is  possible  with  a  meager  number  of  attendants. 
Strict  rules  are  enforced  as  to  ill-treatment  of  patients,  and  dur- 
ing the  past  year  two  attendants  were  placed  under  arrest  on 
evidence  that  they  had  ill-treated  a  patient. 

Restraint  and  seclusion  have  been  reduced  to  a  minimum, 
although  it  is  unfortunate  that  some  of  the  attendants  regard  the 
latter  as  "just  for  punishment."  The  more  objectionable  forms 
of  restraint  have  been  abolished,  including  leather  muffs,  wrist- 
lets, and  straps. 

A  fair  percentage  of  the  patients  are  occupied,  but  there  are 
no  occupational  classes  and  work  is  unsystematized.  There  are 
but  limited  facilities  for  recreation. 

Both  sexes  occupy  both  buildings,  and  separation  of  sexes  is 
4  [49] 


poor.  While  communicating  doors  between  their  respective 
wards  are  supposed  to  be  kept  locked,  it  was  admitted  that  such 
a  condition  is  only  obtained  with  difficulty.  This  is  the  more 
serious  by  reason  of  the  large  number  of  defectives  cared  for,  who 
present  no  evidence  of  insanity.  No  effort  is  at  present  made  to 
discharge  them,  as  in  the  past,  when  discharged,  they  have 
either  been  recommitted  as  insane  or  been  returned  to  the  alms- 
house,  in  which  circumstance  it  is  the  policy  of  the  Directors  to 
have  them  committed  as  insane,  although  admittedly  without 
mental  symptoms,  apart  from  defectiveness. 

As  one  of  the  insane  buildings  should  be  at  once  abandoned 
and  as  the  almshouse  is  overcrowded  every  winter,  it  would 
appear  desirable  that  the  insane  be  removed  from  this  institu- 
tion and  the  almshouse  given  the  use  of  the  more  recently  con- 
structed building  for  the  insane. 

INSTITUTION  No.  32 

Physical  Conditions. — The  insane  hospital  with  the  adjoining 
almshouse  is  maintained  by  a  specially  created  Poor  District, 
but  the  two  institutions  are  independently  administered,  except 
as  supplies  for  both  are  purchased  together.  The  building  for 
the  insane  is  not  unsatisfactory,  except  for  such  defects  as  poor 
natural  lighting  in  places,  defective  ventilation,  and  certain  other 
less  important  defects,  all  of  which  could  be  improved  by  altera- 
tions. The  main  almshouse  building  is  the  superior  structure, 
and  so  far  as  structural  conditions  are  concerned  is  better  adapted 
for  the  insane  than  is  the  building  now  used  for  them. 

There  are  two  separate  laundries,  two  storerooms,  two  kitchens, 
etc.,  but  space  is  lacking  for  adequate  service  facilities  for  the 
hospital,  several  such  departments  being  in  the  basement  with 
especially  poor  light  and  ventilation. 

The  upper  sashes  in  the  hospital  are  permanently  fastened, 
the  lower  ones  being  guarded  by  outside  straight  iron  bars. 
Varying  sized  dormitories  provide  fair  classification  at  night,  but 
day  classification  is  unsatisfactory.  Excellent  porches  for  de- 
crepit patients  constitute  a  good  feature.  On  all  wards  there  is 
a  lack  of  chairs  and  benches,  patients  lying  on  the  floor,  even  in 
the  passages  to  the  water  sections. 

Ventilation  is  generally  defective,  a  distinct  odor  being  ob- 
served throughout  the  institution,  but  it  is  especially  marked  in 

[50] 


the  infirmary.  There  is  a  system  of  ventilating  flues,  but  the 
fact  that  the  openings  to  them  were  in  several  instances  stuffed 
with  socks  and  old  rags  may  have  had  some  relation  to  the  con- 
dition found. 

There  are  no  special  reception  wards,  while  the  infirmaries  for 
the  sick  lack  special  facilities.  There  is  no  provision  for  isola- 
tion of  tubercular  or  contagious  cases.  There  are  no  hydro- 
therapeutic  apparati,  no  facilities  for  pathological  work,  and 
but  crude  facilities  for  the  meager  amount  of  clinical  laboratory 
work  done. 

The  toilet  facilities  are  insufficient,  despite  which  two  toilet 
sections  were  found  unused,  it  being  explained,  "It's  hard  to 
watch  them  in  here  and  they're  apt  to  hurt  themselves."  Some 
toilets  were  out  of  order  and  emitting  an  odor.  The  plumbing 
is  old  and  some  leaks  were  observed.  Hot  water  safety  devices 
were  lacking  and  it  was  admitted  that  at  least  one  patient  has 
been  seriously  scalded  by  hot  water. 

Two  basement  dining-rooms  are  particularly  objectionable, 
being  dark  and  ill-ventilated  as  well  as  devoid  of  furniture 
except  bare  tables  and  chairs.  Old  dented  tinware  is  used. 
The  two  main  dining-rooms  have  windows  on  but  one  side,  so 
light  and  air  are  also  deficient  in  them.  The  food  elevators  are 
lined  with  wood,  and  although  the  local  authorities  recommended 
that  they  be  replaced  over  two  years  ago,  no  action  was  ever 
taken.  The  basement  kitchen  is  also  poorly  lighted  and  ven- 
tilated. While  there  is  a  direct  refrigerating  plant,  it  is  badly 
located  at  the  rear  of  the  dynamo  room,  which  in  turn  is  at  the 
rear  of  the  kitchen  and  laundry.  The  entrance  to  the  plant  is 
at  the  side  farthest  from  the  kitchen,  and  here  considerable 
refuse  was  noted. 

The  water  supply  is  limited,  but  could  be  improved  by  addi- 
tional wells,  the  single  well  now  used  in  conjunction  with  other 
supply  having  a  good  flow.  The  sewage  flows  untreated  into  a 
neighboring  river.  Fire  protection  is  fair,  but  could  be  improved. 
A  considerable  quantity  of  rags  and  some  refuse,  including  a  pile 
of  mouldy  shoes,  were  found  in  the  basement,  although  a  trusty 
patient  was  seen  here  smoking  a  pipe. 

Administration. — The  housekeeping  is  generally  poor;  in  the 
male  infirmary  sputum  was  seen  on  the  floor  with  flies  clustering 
about.  Here  also  soiled  linen  was  found  stored  in  a  bathtub. 

[51] 


All  the  toilet  sections  were  in  disorder;  water  was  splashed  about 
and  in  one  bathroom  the  central  floor  drain  was  obstructed  by 
the  contents  of  a  cuspidor  emptied  over  it. 

The  food  service  was  unusually  poor;  patients  straggle  in  a 
few  at  a  time  and  immediately  proceed  to  seize  the  food  placed 
on  the  tables  before  their  entrance.  The  food,  however,  is  satis- 
factory, but  a  bad  feature  is  the  practice  of  allowing  some  pa- 
tients extra  food  supplies  at  the  discretion  of  attendants.  There 
appears  to  be  an  unnecessary  amount  of  food  waste,  but  it  is  not 
locally  regarded  as  waste,  as  the  hospital  sells  garbage  to  the 
almshouse  for  the  privilege  of  buying  pork  under  the  market 
price. 

Occupation  receives  some  attention,  but  there  are  no  special 
occupational  classes  or  re-educational  work,  as  such.  Patients 
working  on  the  farm  are  under  the  direction  of  the  almshouse 
superintendent  after  leaving  the  ward.  The  matter  of  exercise 
receives  attention,  and  a  good  feature  is  the  absence  of  an  enclosed 
exercise  yard.  There  are  some  recreations,  but  their  employment 
is  unsystematized.  There  is  an  assembly  hall  on  the  fourth  floor, 
and  while  there  are  outside  fire-escapes,  these  do  not  obviate  the 
danger  of  panic  in  case  of  fire. 

The  patients'  clothing  is  of  fair  quality,  but  receives  little 
attention,  being  disordered  in  the  majority  of  cases  and  not  in- 
frequently torn.  Even  with  the  women,  when  clothing  was  so 
torn  as  to  expose  patients'  limbs  and  bodies,  the  matter  appa- 
rently was  regarded  with  indifference.  Although  there  is  an 
insufficient  force  of  attendants,  discipline  appears  poor  and  per- 
sonal attention  seems  even  less  than  would  be  possible  with  the 
number  of  attendants  provided.  For  instance,  a  male  patient 
was  found  locked  in  his  room,  both  bed  and  floor  being  in  a  foul 
condition,  as  well  as  the  patient's  person,  but  the  door  to  the 
room  was  again  locked  without  comment  being  made.  Another 
man  locked  in  his  room  was  found  nude  on  a  mattress,  the  only 
article  in  the  room;  he  was  said  to  be  dangerous  and  the  door 
was  opened  with  caution,  but  he  responded  to  greeting  with  a 
smile  and  made  no  hostile  move.  Another  secluded  man  was 
noisy  and  pounding  on  the  window-sill  with  a  tin  cup,  no  effort 
being  made  to  take  it  from  him.  A  secluded  woman  had  bits 
of  food  on  the  bed  and  smeared  on  her  person,  and  every  patient 
found  secluded  was  either  nude  or  partially  so,  while  such  cloth - 

[52] 


ing  as  they  possessed  was  in  most  cases  soiled.  On  all  wards 
patients  were  allowed  to  roam  about  in  a  disorderly  manner, 
attendants  giving  no  heed,  unless  an  altercation  between  them 
occurred.  Many  patients  were  barefooted,  especially  in  the 
infirmaries,  where  bed  patients  wandered  about  in  their  night 
clothes,  which  in  some  instances  were  soiled.  In  the  women's 
infirmary,  with  thirty  beds,  no  attendant  was  seen  for  five  minutes 
after  entering  the  ward. 

The  boast  is  made  that  abuse  of  patients  has  been  abolished 
here  and  it  is  true  there  appears  no  evidence  of  physical  abuse, 
but  the  above  clearly  indicates  neglect.  It  was  said  that  re- 
straint was  rarely  used  and  that  half  a  dozen  cases  were  a  fair 
daily  average  for  the  number  in  seclusion.  However,  twenty- 
one  patients  were  counted  who  were  locked  in  their  rooms,  and 
when  this  fact  was  mentioned  it  was  explained  that  to  merely 
lock  a  patient  in  his  room  was  not  seclusion  unless  it  was  against 
the  patient's  will. 

The  clinical  records  are  worthless  from  a  psychiatrical  stand- 
point. Emphasis  is  laid  on  the  physical  findings,  which,  excel- 
lent though  they  be,  do  not  render  any  the  less  regrettable  the 
fact  that  in  many  instances  no  mental  notes  at  all  are  deemed 
necessary.  The  modern  classification  of  insanity  is  deemed 
undesirable.  It  is  explained  that  the  practicing  physicians  in 
the  neighborhood  are  unfamiliar  with  it,  and  there  is  evidently 
no  conception  of  the  institution  as  a  disseminator  of  psychiatrical 
knowledge. 

As  contrasted  with  the  conditions  in  the  hospital,  the  alms- 
house  is  administered  on  a  much  higher  plane.  There  is  evidence 
that  the  inmates  receive  good  personal  attention,  the  general 
housekeeping  is  excellent,  and  the  service  departments  are  not 
only  better  arranged  but  better  conducted.  As  the  almshouse 
has  never  yet  been  filled  to  capacity,  and  in  view  of  the  excellent 
material  conditions  there  obtaining,  it  would  appear  entirely 
feasible  to  provide  accommodations  elsewhere  for  the  almshouse 
inmates,  taking  over  this  whole  plant  for  the  care  of  the  insane. 
The  defects  of  the  institution  as  a  whole  are  administrative 
rather  than  material.  The  more  serious  of  the  material  defects, 
moreover,  are  remediable  without  undue  expenditure. 


53 


INSTITUTION  No.  33 

Physical  Conditions. — The  insane  live  in  the  main  almshouse 
building.  The  women  occupy  the  second  floor  of  one  wing,  with 
a  few  beds  on  the  third  floor,  where  some  patients  live  with  the 
pauper  women.  The  men  occupy  the  second  and  third  floors  of 
the  opposite  wing  and  have  wards  to  themselves.  The  women's 
wards  are  provided  with  plants.  The  women  are  allowed  to 
decorate  their  rooms  with  their  personal  possessions  and  they 
are  not  unattractive  in  appearance.  The  men's  wards,  however, 
are  bare  and  bleak,  possessing  no  decorative  features  whatso- 
ever. Chairs  and  benches  are  both  provided,  but  the  latter 
predominate  on  the  men's  side.  Throughout  the  building,  in- 
terior repairs  are  needed,  side  walls  and  floors  being  broken  in 
numerous  places  and  paint  generally  is  lacking.  There  is  in- 
sufficient day  space  and  the  patients  were  generally  found  in  their 
rooms.  Toilet  accommodations  are  insufficient,  the  plumbing 
is  old,  and  much  of  it  is  concealed  in  the  walls,  but  it  is  kept  in 
good  repair.  While  iron  beds  are  used,  they  are  poorly  con- 
structed and  several  were  noticed  with  parts  loose.  Straw  ticks 
are  used,  but  the  bedding  is  clean  and  the  housekeeping  generally 
good,  especially  on  the  women's  side. 

Although  the  pauper  inmates  and  the  insane  have  separate 
tables,  they  eat  in  the  same  dining-rooms,  the  children  eating 
with  the  women.  The  dining-room  appointments  are  crude,  the 
dietary  is  stereotyped  and  bread  and  molasses  with  either  tea 
or  coffee  form  the  staples  for  breakfast  and  supper;  the  food  is 
apparently  sufficient,  however.  The  kitchen  has  little  equip- 
ment. There  is  a  general  lack  of  fly-screens  and  flies  were 
numerous  on  the  occasion  of  the  visit.  Most  of  the  service 
departments  are  in  the  basement,  where  light  and  air  are 
deficient. 

Raw  sewage  flows  into  a  neighboring  creek.  There  is  fair 
fire  protection,  but  there  are  no  outside  hydrants.  Water 
pressure  is  obtained  from  an  elevated  water  tower,  filled  by  a 
single  pump  in  the  power-house,  and  the  risk  of  depending  on  a 
single  pump  has  caused  the  Directors  to  consider  another  pump 
near  the  water  tower.  An  unnecessary  fire  risk  arises  from 
naked,  natural  gas  flames  in  the  men's  toilet  sections  and  in  some 
of  the  basement  service  rooms. 

The  farm  buildings  are  in  fair  condition,  except  a  more  or  less 

[541 


dilapidated  piggery,  which  is  too  close  to  the  main  buildings. 
A  new  one  is  planned,  however. 

A  good  feature  is  a  small  frame  structure  for  contagious  dis- 
eases, erected  largely  by  inmate  labor  at  small  expense.  At  the 
time  of  the  visit  no  insane  patients  were  here,  but  it  was  occupied 
by  two  tubercular  and  one  syphilitic  pauper.  There  are  no  other 
special  medical  facilities,  however,  and,  of  course,  under  the 
conditions,  proper  classification  of  the  insane  is  impossible. 

Administration. — There  is  an  atmosphere  of  kindness  here; 
the  patients  appear  to  receive  an  unusual  amount  of  personal 
attention,  and  the  care  given,  considered  as  custodial  care  only, 
is  good.  No  seclusion  is  employed,  as  it  is  deemed  worse  than 
restraint.  The  latter  has  been  reduced  to  a  minimum,  although 
it  is  occasionally  employed  at  the  discretion  of  the  lay  superin- 
tendent. The  forms  used  include  leather  muffs,  wristlets,  and 
straps. 

The  visiting  physician  calls  but  three  times  a  week,  or  as  his 
presence  may  be  deemed  necessary  by  the  superintendent.  The 
medical  work  is  limited  to  the  alleviation  of  physical  ills.  No 
medical  records  are  kept,  the  visiting  physician  frankly  admitting 
that  he  cannot  afford  to  keep  any  for  the  salary  paid.  While  he 
passes  on  the  patients'  condition  for  discharge,  the  initiative 
proceeds  from  the  superintendent. 

A  feature  of  unusual  excellence  is  the  manner  in  which  occu- 
pation has  been  developed,  the  value  of  work  as  a  therapeutic 
agent  being  here  recognized  and  employed  as  such. 

The  matter  of  exercise  for  idle  patients  is  emphasized,  although 
unfortunately  the  exercise  yards  have  the  usual  fence  about 
them.  The  lack  of  recreation  has  evidently  appealed  to  one  of 
the  Directors,  as  he  is  said  to  have  agreed  to  furnish  at  his  own 
expense  several  entertainments  during  the  coming  winter. 

Alleged  cases  of  insanity  are  brought  here  pending  commit- 
ment, if  they  are  not  taken  to  jail.  If  brought  here  they  are 
cared  for  with  the  committed  cases  without  discrimination  being 
made.  The  issue  as  to  where  commitment  shall  be  made  is  de- 
termined by  the  Board  of  Poor  Directors,  although  the  lay 
superintendent's  recommendation  is  often  taken;  the  decision 
is  not  determined  by  medical  considerations,  the  troublesomeness 
of  the  patient  being  the  main  feature  considered. 

While  this  institution  must  be  ranked  as  one  of  the  better 

[551 


ones  of  its  class,  so  far  as  administration  is  concerned  this  is 
untrue  as  to  material  conditions.  Moreover,  the  insane  receive 
no  medical  treatment  directed  to  the  cure  or  improvement  of 
their  mental  condition,  and  the  care  given  is  pauper  care.  It 
would  therefore  appear  desirable  to  remove  the  insane  to  a  cura- 
tive institution.  The  quarters  now  occupied  by  them  could  be 
well  used  by  pauper  inmates,  some  of  whom  now  occupy  a  small 
detached  building  at  the  rear  of  the  main  building,  which  is  much 
less  desirable  than  the  main  building,  even  considering  the  lat- 
ter's  defects. 

INSTITUTION  No.  34 

Physical  Conditions. — The  insane  occupy  wings  extending  at 
right  angles  from  either  end  of  the  almshouse  building ;  there  is  a 
ward  on  each  of  two  floors  for  each  sex.  The  wards  are  in  the 
form  of  narrow  hallways  with  rooms  on  either  side,  and  apart 
from  a  small  day  room  on  the  ground  floor,  the  only  day  space  is 
in  the  halls  and  is,  therefore,  insufficient.  In  several  of  the  pa- 
tients' rooms  the  plaster  has  fallen.  The  windows  have  heavy, 
prison-like  iron  guards.  The  bed-rooms  have  no  lights,  although 
the  doors  are  locked  at  night.  The  only  toilet  facilities  provided 
at  night  are  tin  pots.  Most  of  the  doors  to  the  patients'  rooms 
are  lined  on  the  inside  with  tin  and  in  several  instances  the  side 
walls  are  so  lined  to  prevent  the  patients  from  damaging  the 
plaster.  The  wards  are  bare  of  decorative  features  and  are  un- 
attractive in  appearance. 

The  toilet  facilities  and  the  single  bathtub  provided  for  each 
sex  are  apparently  sufficient  for  the  small  number  of  patients 
cared  for,  but  the  two  tubs  are  also  used  by  the  pauper  inmates  of 
the  almshouse,  although  on  different  days.  There  is  but  a  single 
day-attendant  for  each  sex,  and  on  the  occasion  of  the  visit 
women  patients  were  bathing  without  an  attendant.  No  hot 
water  safety  device  is  provided. 

The  dining-rooms  have  windows  on  one  side  only  and  hence 
the  light  and  ventilation  are  defective.  The  insane  and  pauper 
inmates  eat  in  the  same  rooms,  but  at  different  tables.  The  food 
service  is  poor,  although  it  is  directed  as  well  as  possible  by  the 
single  day-attendant  on  each  side.  The  food  is  abundant,  but 
lacks  variety.  Considerable  food  waste  results  from  poor  ser- 
vice and  lack  of  proper  supervision. 

[56] 


Natural  gas  burners  are  used,  and  while  they  are  protected  in 
the  insane  wards,  naked  flames  were  seen  in  the  almshouse  and 
in  the  basement  beneath.  This  is  supposed  not  to  be  dangerous, 
it  being  said:  "Nothing  is  allowed  to  come  near  them  that  will 
burn."  The  steam  radiators  are  in  part  protected,  but  those  in 
the  women's  toilet  section  and  in  the  dining-rooms  are  un- 
screened. 

In  general,  the  service  departments  are  well  conducted,  their 
chief  defect  being  lack  of  space  and  equipment. 

The  water  supply  is  excellent  and  abundant.  The  sewage 
disposal  is  unsanitary,  with  raw  sewage  flowing  into  a  neighbor- 
ing creek. 

A  high  iron  picket  fence  surmounted  by  barbed  wire  encloses 
the  exercise  yard.  A  bare  path  worn  in  the  earth  about  a  tree  in 
the  yard  where  a  patient  mechanically  trots  day  after  day  is  an 
instance  of  misdirected  energy,  which  under  proper  conditions 
could  be  rendered  productive,  again  illustrating  the  futility  of 
the  attitude,  which  regards  chronic  cases  as  unworthy  of  special 
attention. 

Aside  from  a  crude  operating  room  in  the  almshouse  there  are 
no  special  medical  facilities.  There  is  a  sick  dormitory  for  each 
sex,  where  the  sick  insane  are  taken,  but  these  are  no  different 
from  the  other  almshouse  dormitories.  The  visiting  physician 
calls  regularly  but  once  a  week  and  medical  treatment  is  directed 
only  to  the  relief  of  physical  ills. 

Administration. — In  addition  to  the  single  day-attendant  for 
each  sex,  there  is  a  male  night-attendant  who  makes  rounds 
through  both  the  male  and  the  female  wards,  the  propriety  of 
which  is  certainly  open  to  question.  Under  the  conditions 
patients  are  necessarily  left  alone  much  of  the  time,  and  it  was 
during  the  absence  from  the  ward  of  the  attendant  that  a  male 
patient  committed  suicide  on  April  4,  1913. 

It  was  said  there  were  no  patients  restrained  or  secluded  on 
the  day  of  the  visit,  the  explanation  being  that  troublesome 
patients  were  transferred  to  a  State  hospital.  However,  on 
making  rounds  a  number  of  men  were  found  locked  in  a  small 
day  room,  while  the  attendant  was  shaving  the  other  patients  in 
another  room  at  the  opposite  end  of  the  ward.  On  the  women's 
side,  a  woman  was  found  locked  in  the  day  room,  the  attendant 
being  busy  elsewhere  and  it  being  regarded  as  unsafe  to  trust 

(571 


such  patient  on  the  ward  alone.  It  appears  that  the  term 
seclusion  is  reserved  for  seclusion  in  patients'  rooms  only.  The 
latter  is  at  the  discretion  of  the  lay  superintendent.  Despite  the 
present  lack  of  restraint,  the  male  attendant  spoke  of  a  violent 
case  who  last  year  succeeded  in  doing  considerable  damage,  even 
after  steel  handcuffs  had  been  put  on  him. 

A  patient's  condition  on  discharge  is  determined  by  the  lay 
superintendent,  although  it  was  said  that  he  occasionally  advises 
with  the  visiting  physician. 

The  patients  are  committed  here  by  the  commission  process; 
but  the  issue  as  to  whether  a  patient  shall  be  committed  to  a 
State  hospital  or  to  this  institution  is  determined  by  the  County 
Commissioners.  While  they  assume  to  decide  the  question  on 
the  possibility  of  improvement  and  the  need  of  active  treatment, 
they,  as  laymen,  receive  no  medical  advice,  except  incidentally; 
and  as  a  matter  of  practice  there  is  reason  to  believe  that  the  de- 
gree of  troublesomeness  manifested  by  the  patients  is  a  deter- 
mining factor.  The  lay  superintendent  of  this  institution  makes 
recommendation  when  such  alleged  cases  are  confined  here  and 
it  was  admitted  that  such  recommendation  was  usually  followed, 
as  it  is  in  the  transfer  of  any  committed  case  to  a  State  hospital. 

One  County  Commissioner  asserted  that  all  the  insane  patients 
at  present  in  the  institution  had  been  returned  from  State  hos- 
pitals as  chronic,  but  it  was  learned  from  another  source  that 
this  statement  was  true  of  but  twelve  patients  out  of  the  thirty- 
nine  in  residence.  There  is  every  reason  to  believe  that  there 
are  at  least  several  patients  now  here  who  could  have  been  im- 
proved, if  not  cured,  had  they  received  active  medical  treatment. 

The  almshouse  is  overcrowded  every  winter  and  could  use  the 
insane  wards  to  advantage,  were  the  insane  patients  moved  else- 
where, as  conditions  seem  to  render  advisable. 

INSTITUTION  No.  35 

Physical  Conditions. — This,  in  most  respects,  is  the  best 
County  hospital  in  the  State,  and  it  is  significant  that  it  is  con- 
trolled by  an  independent,  unsalaried  Board  of  Trustees.  There 
is  but  a  single  building,  recently  constructed,  which,  while  pre- 
senting excellent  features,  also  has  some  architectural  defects. 
It  more  closely  approaches  actual  fireproofing  than  is  usual,  and 
as  features  of  unusual  excellence  may  be  mentioned:  Sanitary 

[58] 


bubbling  drinking  fountains,  a  system  of  vacuum  cleaning,  vacu- 
um tubes  leading  from  every  part  of  the  building  to  the  base- 
ment, plaster-lined  linen  shutes  on  every  ward  and  drying  closets 
of  most  modern  character.  The  most  serious  architectural  de- 
fect is  the  want  of  sufficient  natural  lighting,  a  large  number  of 
electric  lights  being  necessary  during  the  day. 

An  objectionable  feature  of  the  site  is  the  almshouse  in  the 
foreground,  while  the  hospital  approach  passes  the  almshouse 
out-buildings,  including  the  hennery  and  the  piggery.  A  serious 
lack  is  the  want  of  acreage,  hospital  being  allowed  only  the  land 
immediately  about  the  building,  which  has  been  set  apart  for 
its  use  out  of  the  entire  County  property,  the  remainder  of  which 
is  regarded  as  belonging  to  the  almshouse. 

There  are  but  two  wards  for  each  sex,  so  little  classification  is 
possible.  The  patients  mingle  in  the  single  large  day  room  found 
on  each  ward.  A  modern  feature  is  the  heavy  wire  window- 
screens  used  in  place  of  the  usual  heavy  iron  bars.  Porch  space 
is  provided,  including  enclosed  porches,  which  afford  partial  iso- 
lation for  tubercular  cases. 

The  result  of  housing  disturbed  patients  in  a  single  day  room 
was  seen  on  the  day  of  the  visit;  although  on  entering  the 
disturbed  ward  it  was  found  comparatively  quiet,  one  patient 
suddenly  began  to  scream  and  in  a  moment  the  whole  ward  was 
in  an  uproar.  An  effort  is  made  to  overcome  this  difficulty  by 
placing  benches  in  a  hollow  square,  so  that  the  more  disturbed 
patients  can  be  kept  apart. 

The  toilet  facilities  are  excellent,  the  plumbing  being  of  the 
most  modern  type.  However  there  are  no  hot-water  safety 
devices.  In  general,  the  ventilation  is  good,  a  special  venti- 
lating system  being  provided.  It  is,  nevertheless,  deficient  in 
the  dining-rooms,  where  the  natural  lighting  is  also  poor. 

The  dining-rooms  possess  an  archaic  feature  in  permanently 
fastened  revolving  chairs,  although  the  other  facilities  are  ex- 
cellent. It  was  admitted  that  such  chairs  occasioned  difficulty 
in  sweeping  and  cleaning  the  room  and  also  when  it  became  neces- 
sary to  remove  an  epileptic  seized  with  a  convulsion. 

The  kitchen  is  excellent  except  for  its  location  in  the  base- 
ment. The  grooves  in  the  concrete  floor  render  cleaning  some- 
what difficult.  For  the  want  of  other  available  space,  the  service 
departments  generally  are  likewise  in  the  basement,  where  the 

[59l 


light  and  air  are  deficient.  An  unnecessary  fire  risk  is  involved 
in  the  storage  of  lubricating  oil  and  kerosene  in  the  carpenter 
shop. 

The  power-house  is  the  only  service  facility  used  in  conjunc- 
tion with  the  almshouse,  it  being  under  the  direction  of  the  alms- 
house  steward.  When  the  hospital  was  built  an  addition  was 
constructed  to  the  power-house,  but  it  is  too  small,  it  being  neces- 
sary to  place  the  air  compressors  and  pumps  so  close  to  the  boil- 
ers that  the  bearings  of  the  former  must  necessarily  be  injured. 
The  lack  of  proper  natural  lighting  renders  the  electrical  load 
heavier  than  would  otherwise  be  necessary. 

Continuous  baths  are  provided,  but  they  are  poorly  located 
in  that  a  single  one  is  on  each  ward,  so  a  single  attendant  has  to  be 
detailed  to  each,  and  hence  it  is  never  possible  to  use  more  than 
one  or  two  at  a  time.  There  is  no  other  hydrotherapeutic  ap- 
paratus. A  modern  operating  room  is  provided,  adjoining  which 
a  small  clinical  laboratory  has  recently  been  fitted  up;  it  is  un- 
fortunate that  the  sterilizing  apparatus  was  not  placed  in  an 
available  anteroom  instead  of  in  the  operating  room  itself.  Ad- 
joining are  two  excellent  modern  hospital  wards  intended  for  the 
respective  sexes,  but  as  yet  unused  except  for  sick  attendants. 
At  present,  special  dormitories  on  the  wards  proper  are  reserved 
for  sick  cases  and  for  new  patients. 

There  is  an  excellent  amusement  hall  and  chapel  with  a  grand 
piano  purchased  by  the  Board  of  Trustees,  and  the  attention 
paid  to  recreation  is  most  commendable. 

Administration. — An  atmosphere  of  kindness  prevails.  The 
patients  receive  good  personal  attention,  and  for  the  most  part 
were  found  in  a  neat  and  tidy  condition. 

Restraint  and  seclusion  can  only  be  used  on  the  physician's 
order, — the  amount  employed  is  larger  than  will  ultimately  be 
the  case,  as  there  is  at  present  an  undue  proportion  of  disturbed 
cases,  due  to  transfers  from  other  institutions,  when  the  hospital 
was  opened  less  than  a  year  ago.  Another  factor  is  the  inex- 
perience of  the  attendants,  likewise  due  to  the  youth  of  the  in- 
stitution. 

A  fair  percentage  of  the  patients  are  employed,  especially  when 
the  great  lack  of  occupational  opportunity  is  considered.  There 
are  as  yet  no  occupational  classes,  but  it  is  planned  to  establish 
some  in  the  near  future.  Special  attention  is  given  the  matter 

[60] 


of  exercise,  and  this  is  one  of  the  few  County  institutions  where 
an  enclosed  exercise  yard  is  deemed  unnecessary.  Special  op- 
portunity is  given  for  exercise  of  the  indoor  workers. 

The  medical  work  is  satisfactory,  so  far  as  the  facilities  permit, 
and  this  is  the  only  County  hospital  for  the  insane  where  there  is 
any  medical  treatment  for  the  relief  of  mental  diseases  as  such. 
The  medical  records  are  above  the  average.  While  there  is  no 
pathological  work  as  yet,  it  is  to  be  undertaken  shortly. 

In  general,  a  progressive  spirit  is  manifest,  and  it  is  very  evi- 
dent that  the  local  officers  and  the  Board  of  Trustees  work  in 
harmony,  with  the  best  interests  of  the  patients  and  of  the  in- 
stitution as  their  sole  aim. 

The  proximity  of  the  almshouse  to  the  hospital  is  objection- 
able, as  under  similar  circumstances  elsewhere.  Most  of  the 
buildings  of  the  former  could  be  remodeled  at  comparatively 
small  expense,  for  certain  classes  of  the  insane,  and  could  this 
whole  plant  be  utilized  as  an  insane  hospital,  the  chief  defects 
of  the  present  hospital  would  be  at  once  eliminated,  i.  e.,  lack  of 
opportunity  for  classification  and  occupation,  especially  outdoor 
work.  The  best  of  the  almshouse  buildings,  the  almshouse 
hospital  building,  is  unusually  well  arranged  for  an  infirmary 
unit  and  would  require  no  alterations  except  minor  repairs. 
The  other  almshouse  buildings,  while  less  satisfactory,  present 
no  unsurmountable  obstacles  preventing  their  use  for  the  insane. 
As  this  institution  is  located  near  a  center  of  population,  it  would 
appear  most  desirable  to  provide  accommodations  for  the  aims- 
house  elsewhere  and  utilize  the  entire  plant  for  the  insane. 

INSTITUTION  No.  36 

Physical  Conditions. — Separate  buildings  are  provided  for  the 
male  and  the  female  insane,  respectively,  both  located  at  the 
rear  of  the  almshouse.  The  men's  building  is  of  recent  con- 
struction and  is  practically  fireproof,  but  is  poorly  designed  for  its 
purpose.  There  is  but  a  single  ward  on  each  of  the  two  floors, 
so  little  opportunity  is  afforded  for  classification.  It  is  provided 
with  inside  stone  stairways  in  lieu  of  fire  escapes,  which,  however, 
lead  to  the  basement  only.  In  the  original  plan,  no  provisions 
were  made  for  a  dining-room,  so  a  basement  room  is  used,  where 
the  light  and  air  are  both  defective.  To  reach  this  dining-room 
food  is  carried  in  tin  wash-boilers  across  an  open  yard  to  a  base- 

[61] 


ment  passageway.  No  provision  originally  made  for  employees 
and  hence  makeshift  arrangements  are  now  necessary.  The  halls 
are  narrow ;  inside  iron-barred  window  guards  emphasize  the  idea 
of  restraint,  and  despite  the  fact  that  the  building  is  compara- 
tively new,  the  side  walls  are  cracked  to  some  extent  and  in  sev- 
eral places  the  ceiling  plaster  has  fallen;  the  toilet  facilities  are 
insufficient  for  the  number  of  patients,  especially  wash-basins. 

The  women's  building  is  older  and  even  less  satisfactory, 
save  that  it  has  a  better  dining-room.  There  are  numerous 
narrow  dark  passageways,  the  walls  are  still  more  cracked,  and 
paint  is  generally  needed.  The  toilet  accommodations  are  also 
less  satisfactory  than  in  the  men's  building,  being  limited  in 
amount,  while  the  plumbing  is  old  and  unsanitary.  Despite 
adverse  conditions,  the  housekeeping  is  excellent  throughout  the 
institution. 

The  fire  protection  is  defective,  especially  in  the  women's 
building;  there  is  an  elevated  water  tank  to  afford  gravity 
water  pressure,  but  it  is  filled  by  a  single  pump,  so,  in  case  of 
accident  to  the  latter,  the  institution  would  be  without  water 
protection.  There  is  no  fire  fighting  apparatus  of  any  descrip- 
tion in  the  men's  building.  In  the  women's  building  there  is  a 
small  hose  with  standpipes,  but  as  the  latter  connect  only  with 
small  attic  tanks  filled  by  rain-water,  they  afford  meager  protec- 
tion. There  are  three  outside  fire-escapes,  but  the  approach  to 
one  from  the  third  floor  is  by  a  window  shut  off  by  permanently 
fastened  iron  window  guards. 

The  service  departments  are  well  conducted,  but  in  most  in- 
stances space  and  proper  equipment  are  lacking.  The  laundry 
is  poorly  located  in  a  detached  building,  in  front  of  the  building 
for  women  patients. 

The  farm  buildings  are  old  and  generally  dilapidated.  An 
old,  unsanitary,  frame  piggery  is  located  within  three  hundred 
yards  of  the  women's  building.  It  was  said  that  the  Board  of 
Poor  Directors  at  one  time  planned  to  build  a  new  piggery,  fol- 
lowing the  condemnation  of  the  present  one  by  the  Grand  Jury, 
but  it  was  finally  determined  to  defer  the  matter  for  another  year. 

An  exercise  yard  is  provided  for  each  sex.  The  one  for  men  is 
enclosed  with  wire  screening  and  is  of  good  size  but  lacks  any 
seating  facilities.  The  one  for  women  is  too  small,  there  are  no 
shade  trees,  the  most  of  the  grass  has  been  worn  off,  and  it  is  a 

162] 


most  desolate  appearing  spot;  it  is  enclosed  by  an  old,  unpainted, 
high  board  fence,  which  completely  shuts  off  the  view.  This 
yard  also  lacks  seating  facilities,  and  when  seen  patients  were 
crowded  together  on  the  ground  or  were  restlessly  pacing  back 
and  forth.  The  local  authorities  plan  a  larger  exercise  yard  for 
the  women,  but  unfortunately  they  consider  it  necessary  to 
erect  a  high  concrete  wall  about  it. 

There  is  a  surgical  operating  room,  poorly  located  at  one  side 
of  the  entrance  to  the  administrative  office  in  the  men's  building, 
but  otherwise  there  is  an  entire  lack  of  special  medical  facilities. 

Administration. — The  superintendent,  who  is  a  physician,  has 
charge  of  the  adjoining  almshouse,  and  there  being  no  steward, 
his  time  is  largely  occupied  with  business  and  administrative 
details,  so  the  medical  work  is  directed  only  to  the  relief  of  physi- 
cal conditions.  During  his  tenure  of  office  he  has  made  a  con- 
siderable number  of  material  improvements,  and  has  more 
planned.  He  has  also  introduced  greatly  improved  business 
methods,  especially  in  the  matter  of  purchases  and  the  checking 
of  supplies. 

With  but  few  exceptions,  the  patients  present  a  tidy  appear- 
ance, and  they  apparently  receive  as  much  personal  attention  as 
is  possible  with  the  limited  number  of  attendants.  As  evidence 
of  this  may  be  cited  the  excellent  results  attending  the  effort 
made  to  reduce  restraint  and  seclusion  to  a  minimum,  especially 
commendable  in  view  of  the  absence  of  hydrotherapy.  One 
patient  admitted  here  from  another  hospital  is  said  to  have  been 
restrained  for  several  months  prior  to  the  transfer,  but  by  means 
of  special  personal  attention  such  patient  has  never  been  re- 
strained here  and  has  recently  been  induced  to  do  some  work. 

There  is  a  fair  percentage  of  the  patients  occupied,  but  there 
are  no  special  occupational  classes.  There  is  little  opportunity 
for  recreation,  but  emphasis  is  placed  on  the  matter  of  exercise. 

Two  of  the  women  patients  have  with  them  their  illegitimate 
children,  one  fourteen  months  old  and  the  other  eighteen  months 
old.  Both  children  accompanied  the  mothers  when  the  latter 
were  admitted,  although  nothing  was  said  about  the  children  in 
the  commitment  papers.  In  one  case  the  infant's  maternal 
grandmother  is  also  a  patient,  and  although  considerably  de- 
mented, was  seen  holding  the  child  as  she  sat  on  the  steps  leading 
to  the  exercise  yard,  while  all  about  were  the  other  women  pa- 

[63] 


tients,  some  of  whom  were  restless  and  talkative.  The  local 
authorities  have  no  idea  as  to  what  disposition  will  be  made  of 
the  children,  although  they  hope  to  make  other  arrangements 
soon. 

One  woman  patient  was  described  as  a  moral  imbecile,  and 
certain  it  is  she  fails  to  present  any  evidence  of  insanity ;  she  has 
had  five  illegitimate  children,  and  is  regarded  as  utterly  incorri- 
gible, which  appears  to  be  the  only  basis  upon  which  her  commit- 
ment as  insane  rests. 

The  Board  of  Poor  Directors  are  perhaps  too  economically 
inclined,  and  it  was  only  with  much  difficulty  that  they  were 
finally  convinced  of  the  necessity  of  painting  the  women's  build- 
ing, although  it  had  not  been  painted  for  fourteen  years.  How- 
ever, the  Board  is  said  to  be  of  a  higher  caliber  than  former 
Boards.  It  is  said  that  a  former  Director  once  vigorously  pro- 
tested against  any  expenditure  for  bathtubs,  arguing  that  as  he 
had  none  in  his  own  house  he  did  not  see  why  the  County  institu- 
tion should  be  so  equipped. 

The  care  given  is  necessarily  custodial  care  only,  and  as  the 
buildings  here  are  so  unsatisfactory  for  the  insane,  it  would  seem 
desirable  to  remove  such  patients  to  a  medical  institution. 
Should  such  course  be  followed,  the  almshouse  inmates  could  use 
the  new  building  occupied  by  the  male  insane,  as  neither  the 
building  for  the  women  insane  nor  the  almshouse  building  is 
worth  the  extensive  and  expensive  repairs  required  to  render  them 
satisfactory. 

INSTITUTION  No.  37 

Physical  Conditions. — A  wing  extends  at  right  angles  from 
either  end  of  the  almshouse  for  the  respective  sexes  of  the  insane ; 
however,  the  insane  occupy  only  the  first  and  second  floors,  the 
third  being  used  by  paupers.  The  wards  are  short  halls  with 
rooms  on  either  side  and  a  small  day  room  at  one  end.  None 
of  the  patients'  rooms  are  sufficiently  large  to  properly  accommo- 
date more  than  two  beds,  but  some  contain  three  and  four. 
The  side  walls  are  cracked  and  broken,  the  bare  board  floors  are 
worn,  paint  is  everywhere  needed,  and  in  the  absence  of  any 
decorative  features  whatever,  the  wards  present  a  most  bare  and 
desolate  appearance.  There  is  little  furniture,  a  ward  for  twenty 
patients  having  only  three  benches  and  a  table,  while  another 
ward  has  benches,  but  no  table. 

[64] 


Most  of  the  beds  are  of  iron,  but  there  are  a  few  wooden  ones, 
which  it  is  hoped  to  replace  when  funds  are  available.  There 
are  no  service  or  supply  closets,  the  ones  in  the  almshouse  proper 
alone  being  available.  All  the  toilet  facilities  are  in  a  large  open 
room ;  there  should  be  at  least  twice  as  many  toilet  hoppers  pro- 
vided and  four  times  as  many  wash-basins,  considering  the  num- 
ber of  patients  using  them.  Dependence  is  placed  on  natural 
ventilation  only,  and  it  is  particularly  poor  in  the  toilet  sections. 

The  steam  radiators  are  about  to  be  covered  with  protecting 
screens.  Such  protection  was  first  recommended  by  the  State 
Committee  on  Lunacy  eight  years  ago. 

The  pauper  inmates  and  the  insane  eat  in  the  same  dining- 
rooms  and  at  the  same  tables;  stools  without  backs  are  used 
and  the  dining-room  appointments  are  meager  and  crude.  The 
dining-rooms  are  as  cheerless  in  appearance  as  the  wards.  The 
kitchen  has  a  board  floor  broken  in  at  least  one  place,  while 
the  walls  and  ceilings  are  smoked,  stained,  and  scratched.  A 
limited  equipment  renders  it  impossible  to  cook  the  whole  of  a 
single  meal  at  once,  and  as  both  meat  and  soup  were  served  for  the 
meal  inspected,  the  meat  was  placed  on  the  table  while  the  soup 
was  being  prepared  in  the  same  kettle  in  which  the  meat  had  been 
cooked,  so  the  latter  was  cold  by  the  time  the  patients  entered. 
Although  the  food  appears  sufficient  in  amount,  it  is  of  the  usual 
stereotyped  variety;  breakfasts  and  suppers  are  practically  the 
same,  the  staples  being  bread,  either  with  or  without  butter, 
molasses,  and  coffee.  In  summer,  however,  it  is  sometimes  pos- 
sible to  add  for  supper  only,  a  tomato,  a  potato,  beans  or  ginger 
bread. 

The  service  departments  are  for  the  most  part  in  the  base- 
ment, and  considering  the  character  of  the  institution  have  a  fair 
equipment  and  appear  well  conducted. 

The  sewage  flows  untreated  into  a  creek  about  five  hundred 
feet  from  the  main  entrance. 

The  fire  protection  is  poor,  there  being  practically  none  for 
the  insane  wards,  as  the  single  entrance  to  each  ward  is  from  an 
almshouse  hallway  and  while  the  hose  in  the  almshouse  is  suffi- 
cient to  reach  such  entrances,  it  reaches  no  further.  Even  this 
hose  was  found  in  disorder,  being  uncoiled,  and  it  was  admitted  it 
had  not  been  tested  "for  a  long  while."  There  are  only  inside 

s  [65] 


wooden  stairways  in  the  almshouse,  and  but  a  single  outside  fire- 
escape  at  one  end.     There  are  no  outside  hydrants. 

There  is,  of  course,  no  proper  classification,  with  but  two  wards 
for  each  sex. 

An  exercise  yard  for  each  sex  is  provided,  each  being  enclosed 
by  a  plain  high  board  fence.  But  a  single  bench  was  seen  in  the 
women's  yard  and  none  in  the  men's  yard,  so  most  of  the  patients 
sit  or  lie  about  on  the  ground.  There  is  but  a  single  shade  tree 
in  the  women's  yard,  and  neither  shade  nor  shelter  in  the  men's 
yard.  In  the  latter  are  numerous  paths  worn  in  the  earth  by  the 
pacing  back  and  forth  of  the  patients. 

Administration. — Personal  attention  is  necessarily  limited, 
there  never  being  more  than  a  single  attendant  on  day  duty  for 
each  ward.  With  regular  time  allowance  off  duty,  and  with  the 
necessity  of  the  attendants  for  the  insane  assisting  with  the  alms- 
house  work,  the  wards  are  left  alone  much  of  the  time.  The 
patients  are  locked  in  their  rooms  at  night,  but  only  since  July, 
1914,  has  there  been  a  male  and  a  female  night-attendant  em- 
ployed. They  now  make  rounds  at  intervals  during  the  night 
through  both  the  insane  wards  and  the  almshouse,  but  they  do 
not  open  the  doors  of  the  patients'  rooms  except  in  special  cases. 
The  cause  of  the  recent  employment  of  the  night-attend- 
ants was  a  suicide  during  the  month  mentioned.  It  appears  a 
woman  patient  was  admitted  in  a  disturbed  state,  and  was  not 
only  locked  in  her  room  at  night,  but  was  left  in  restraint.  When 
her  room  was  entered  in  the  morning,  it  was  found  that  she  had 
succeeded  in  freeing  herself  from  the  restraint  and  had  hung 
herself  with  the  bed  sheet.  She  was  still  alive  when  found,  but 
died  a  few  hours  later. 

Another  instance  which  can  justly  be  attributed  to  the  lack  of 
a  sufficient  number  of  attendants  was  the  suicide  in  January, 
1914,  of  a  woman  inmate  of  the  almshouse  who  jumped  from  a 
third -story  window. 

In  most  instances,  especially  on  the  male  side,  the  patients' 
clothing  was  found  disordered,  unbuttoned,  and  in  some  instances 
torn,  although  it  should  be  added  it  was  in  the  majority  of  in- 
stances clean.  In  three  instances  observed  on  the  male  wards, 
the  patients'  flesh  showed  through  the  torn  garment,  there  being 
no  evidence  of  underwear.  Several  instances  were  noted  of 
patients  with  shoes,  but  without  stockings  or  socks:  some  men 

[661 


wore  socks,  but  had  no  shoes.  One  woman  was  seen  eating  din- 
ner in  the  dining-room  while  barefooted,  and  later  six  male  pa- 
tients were  seen  in  the  exercise  yard  in  a  similar  condition. 
Here  also  was  found  a  patient  admitted  on  the  day  of  the  visit 
seated  alone  on  the  ground  in  his  shirt-sleeves,  having  received 
no  special  attention. 

On  the  occasion  of  the  visit,  two  women  were  constantly 
secluded  because  of  their  restless  and  untidy  tendencies.  Both 
cases  are  defectives  without  evidence  of  insanity.  No  cases 
were  in  restraint,  it  being  explained  that  disturbed  patients  are 
at  once  transferred  to  other  institutions.  Should  a  new  case 
become  violent  it  is  the  practice  to  strap  the  patient  to  the  bed 
with  leather  straps  about  the  arms  and  legs,  or  in  the  discretion 
of  the  lay  superintendent,  a  strait-jacket  may  be  employed. 

While  the  superintendent  is  active  and  apparently  anxious  to 
do  the  best  possible  for  the  patients,  his  idea  of  the  care  of  the 
insane  is  evinced  by  the  question:  "What  is  the  best  form  of 
restraint?"  It  appears  unfortunate  that  he  should  be  regarded 
as  specially  qualified  for  the  care  of  the  insane  by  reason  of 
experience  obtained  as  turnkey  in  the  County  jail,  where  he  was 
obliged  to  care  for  a  certain  number  of  insane  persons. 

The  practice  exists  here  of  employing  paupers  in  preference  to 
the  insane  and  such  of  the  latter  as  are  occupied  are  the  willing 
workers  only,  there  being  no  occupational  training.  There  is  a 
lack  of  recreation  and  the  patients  lead  a  drab,  colorless  existence. 

There  is  an  entire  lack  of  special  medical  facilities,  an  ordinary 
dormitory  being  set  apart  in  the  almshouse  for  sick  cases;  here 
the  physically  sick  among  the  insane  are  cared  for,  while  the 
practice  also  exists  of  placing  uncommitted  paupers  in  the  insane 
wards,  if,  in  the  judgment  of  the  local  authorities,  special  cir- 
cumstances render  it  advisable.  Throughout  the  institution 
there  is  no  distinction  made  in  the  care  of  the  almshouse  inmates 
and  the  insane.  They  eat  together,  wear  the  same  clothes,  and 
receive  the  same  limited  amount  of  personal  attention.  As  was 
stated:  " There  is  no  favoritism  here ;  everybody,  whether  insane 
or  a  pauper,  is  treated  alike." 

This  institution  has  evidently  suffered  from  being  subjected 
to  political  influences,  although  it  was  said  such  influences  are 
now  less  active  than  formerly.  That  there  has  been  some  local 
recognition  of  defective  conditions  is  evinced  by  the  plans  made 

[67] 


for  a  new  County  insane  hospital,  but  a  dispute  having  arisen 
among  the  local  authorities,  no  action  is  considered  probable  in 
the  near  future. 

The  custodial  care  here  given  is  below  even  the  usual  standard 
of  County  institutions,  and  as  a  mere  matter  of  humanity  the 
insane  patients  should  be  removed  at  the  earliest  possible  mo- 
ment. In  recognition  of  existing  conditions  State  aid  has  been 
withheld  for  the  time  being  by  recommendation  of  the  State  Board 
of  Charities. 

GENERAL  CONSIDERATIONS  OF   COUNTY   INSTITU- 
TIONS FOR  THE  INSANE 

In  reviewing  this  group  of  institutions,  the  most  striking  fea- 
ture is  the  close  association  maintained  between  the  institutions 
for  the  insane  and  almshouses,  in  some  instances  both  the  in- 
sane and  paupers  being  cared  for  in  the  same  building,  and  in  a 
few  cases  in  the  same  ward :  the  inevitable  result  is  that  the  care 
of  the  insane  tends  to  the  almshouse  standard,  and,  indeed,  in 
some  places  an  effort  is  made  to  provide  exactly  the  same  type 
of  care  for  both.  Hence  it  is  not  surprising  that  one  finds  the 
practice  common  of  caring  for  the  insane  in  the  almshouses 
proper  or  the  uncommitted  almshouse  inmates  in  the  insane  de- 
partments, when  in  the  judgment  of  local  authorities  circum- 
stances appear  to  render  it  advisable. 

In  numerous  instances  the  material  conditions  should  be  rem- 
edied for  the  care  of  any  class  of  dependents,  insane  or  other- 
wise, especially  as  regards  unsanitary  sewage  disposal  and  the 
woefully  inadequate  fire  protection  so  often  found. 

As  a  result  of  the  existing  system,  in  these  institutions  custodial 
care  is  generally  substituted  for  active  remedial  treatment  di- 
rected to  the  improvement  or  the  recovery  of  the  insane  as  such. 
As  a  rule,  the  medical  treatment  for  physical  ills  is  satisfactory, 
although  such  is  not  invariably  the  case.  With  but  few  excep- 
tions, the  County  institutions  have  no  special  medical  facilities, 
nor  can  it  be  expected  that  such  facilities  can  be  provided  under 
present  conditions,  for,  with  the  comparatively  small  number  of 
patients  treated  in  the  respective  institutions,  such  provisions 
would  require  a  prohibitive  per  capita  expense;  but  as  a  result 
of  such  lack  of  facilities,  mechanical  means  of  restraint  and  con- 
finement are  substituted  for  proper  personal  treatment  and 

[68] 


attention.  With  but  a  limited  number  of  attendants,  enclosed 
exercise  yards  and  personal  restraint  and  seclusion  must  inevi- 
tably result.  Under  existing  conditions,  one  cannot  blame  the 
caretakers  of  the  insane  for  resorting  to  such  means,  for  while 
restraint  and  seclusion  can  and  should  be  abolished,  they  can- 
not be  successfully  abolished  without  the  substitution  of  other 
means  of  dealing  with  the  disturbed  insane,  such  as  hydrother- 
apy,  occupational  training,  and  close  personal  supervision.  In 
this  connection  it  is  agreeable  to  note  that  little  evidence  was  ob- 
tained of  actual  physical  abuse,  but  that  gross  neglect  exists  is 
indisputable. 

That  the  theory  of  County  hospitals  for  the  chronic  insane 
only  does  not  obtain  in  actual  practice  is  but  a  necessary  result 
of  the  prevailing  custom  of  determining  the  question  as  to  whether 
a  patient  shall  be  committed  to  a  State  hospital  or  to  a  County 
hospital,  regardless  of  prognosis  or  medical  issues,  in  many 
instances  the  decision  being  made  by  local  lay  authorities  with- 
out medical  advice.  It  is  certain  that  many  acute  cases  have 
lapsed  into  chronicity  in  the  County  hospitals  simply  for  lack  of 
proper  treatment.  Dreary,  desolate  wards,  lack  of  recreation, 
or  other  means  of  exciting  or  maintaining  active  interest  are  alone 
sufficient  not  only  to  hinder  improvement  or  recovery,  but  must 
necessarily  result  in  actually  hastening  the  terminal  process  of 
deterioration. 

UNLICENSED  ALMSHOUSES  CARING  FOR  THE  INSANE 

NOS.  38-48 
General  Statistics. — 

Institution  No.  Insane  Inmates 

38 36  (34  committed) 

39 2 

40 9 

4i 2 

42 I 

43 3 

44 6 

45 6 

46 8 

47 2 

48 7 

Total  insane 82 

None  of  these  institutions  is  apparently  deemed  worthy  by  the 
State  Board  of  Charities  to  receive  State  aid  and,  accordingly, 

[69] 


none  is  licensed,  yet  three  have  locally  recognized  insane  depart- 
ments, while  in  the  others  the  number  of  inmates  above  indicated 
were  found  actually  insane,  although  cared  for  without  discrimi- 
nation with  the  other  paupers.  Excepting  only  the  thirty-four 
inmates  indicated,  none  has  ever  been  committed.  In  addition 
to  the  insane,  one  hundred  and  ninety-six  defectives  were  found, 
ranging  from  the  lowest  grade  idiots  to  high-grade  imbeciles. 
There  are  also  a  large  number  of  dotards;  thirty-three  children 
were  found ;  while  in  one  almshouse  the  conglomerate  mass  of 
humanity  was  found  increased  by  the  practice  of  the  courts  in 
committing  thereto  incorrigible  girls. 

INSTITUTION  No.  38 

There  is  a  separate  building  for  the  insane  located  at  the  rear 
of  the  almshouse  proper.  It  is  partly  brick  and  partly  frame; 
the  sexes  are  divided  by  central  partitions,  and  while  the  com- 
municating doors  are  said  to  be  kept  locked,  one  at  least  was  found 
open.  The  ceilings  are  low;  the  floors  and  in  some  instances  the 
side  walls  need  repair.  Dark,  narrow  passageways  are  numer- 
ous. The  stairs  are  dark,  winding,  and  of  wooden  construction. 
The  windows  are  guarded  outside  by  heavy  iron  bars  set  in  the 
brickwork  and  inside  by  closely  woven,  heavy  wire  screens. 
The  ventilation  is  poor,  especially  in  the  small,  dark  toilet  sec- 
tions, all  crude  in  the  extreme  and  in  a  most  unsanitary  state. 
Bathing  facilities  likewise  are  primitive.  All  the  rooms  are  bare, 
desolate,  and  with  a  prison-like  appearance,  produced  by  the  iron 
bars  at  the  windows  and  in  the  doors  of  the  so-called  "strong 
rooms."  Straw  or  husk  bed-ticks  are  used,  but  the  bed- 
ding, while  coarse,  is  fairly  clean.  The  fire  risk  is  great  and 
fire,  at  night  especially,  would  inevitably  mean  loss  of  life. 
Lighting  is  by  kerosene  lamps;  there  are  no  fire-escapes,  hose  or 
standpipes.  One  of  the  inside  stairways  has  been  removed  and 
the  stair  well  used  for  stores,  while  a  wooden  ventilating  flue 
extends  to  the  roof  from  the  second  floor,  and  both  would  act 
as  flues  in  case  of  fire.  With  windows  guarded  with  iron  bars, 
the  patients  are  locked  in  their  rooms  at  night,  and  left  without 
any  night-attendant,  while  the  day-attendants  sleep  in  an  ad- 
joining building,  it  being  explained  that  after  the  patients  are 
locked  in  their  rooms  at  night  "they  can't  make  any  trouble." 
A  year  ago  a  barn  was  burned,  resulting  in  total  loss,  although  an 

[70] 


outside  hydrant  stands  much  nearer  to  its  site  than  to  the  building 
for  the  insane.  The  radiators  are  unprotected;  an  epileptic  girl 
was  seriously  burned  on  one  some  time  ago,  but  no  action  was 
taken  to  correct  this  condition. 

The  basement  dining-room  is  dark,  ill  ventilated,  and  with  a 
broken  concrete  floor.  The  men  and  women  eat  together,  al- 
though at  separate  tables.  There  are  but  a  few  agateware  dishes, 
and  the  food  service  is  crude  and  haphazard.  All  the  service 
departments  are  in  extremely  poor  condition.  The  sewage 
flows  untreated  into  a  neighboring  creek,  but  below  the  point 
where  part  of  the  water  supply  is  obtained.  Litigation  is  said  to 
have  resulted  from  the  County  Commissioners'  failure  to  adopt 
the  recommendation  of  the  State  Board  of  Health  regarding  the 
sewage  disposal. 

In  many  respects  the  farm  buildings  are  in  better  condition 
than  the  interior  of  the  building  for  the  insane. 

There  is  little  personal  attention,  the  only  attendants  being  a 
married  couple,  who  care  for  the  respective  sexes.  One  patient 
was  seen  with  finger-nails  half  an  inch  long.  The  clothing  was 
generally  disordered  and,  in  some  instances,  torn.  In  one  case 
bed-ticking  was  used  as  suiting.  While  no  patients  were  re- 
strained or  secluded  on  the  day  of  the  visit,  a  woman  had  been 
shortly  released  from  a  strait-jacket  after  three  months'  con- 
finement, her  poor  physical  condition  suggesting  that  this  might 
account  for  the  fact  that  she  was  fairly  quiet  when  seen.  The 
institution  is  provided  with  handcuffs  and  leather  wristlets,  but 
seclusion  is  more  used.  The  "strong  rooms"  are  inside,  have 
but  a  single  window  opening  on  an  inside  passage,  and  are  so 
dark  that  it  is  impossible  to  see  across  them  when  looking  through 
the  iron  bars  of  the  doors.  Medical  treatment  of  even  physical 
ills  is  limited,  the  visiting  physician  calling  but  twice  a  week,  or 
when  the  male  attendant,  who  was  formerly  a  driver,  deems  his 
presence  necessary.  The  attendant  has  full  authority  to  dis- 
charge any  insane  patient  that  he  deems  fit. 

It  is  considered  necessary  here  that  the  exercise  yards  be  en- 
closed, and  from  $1300  to  $1400  is  to  be  spent  for  a  steel  fence, 
replacing  an  old  fence  recently  blown  down,  and  for  a  concrete 
floor  for  the  yard;  meanwhile  the  patients  are  not  allowed  to 
exercise  out-of-doors  unless  they  are  paroled  patients.  No 
opportunity  is  afforded  for  classification,  all  types  mingling  to- 

[71! 


gather  and  the  two  sexes  mingling  in  going  to  and  from  the  din- 
ing-room. There  are  no  recreations,  no  religious  services,  and 
the  patients  lead  a  dull,  monotonous,  mechanical  existence. 

INSTITUTION  No.  39 

Most  defective  material  conditions  exist  here,  even  for  an 
almshouse.  The  main  building  is  four  stories  high,  and  although 
kerosene  lamps  are  the  only  illuminant  there  is  no  fire  protection. 
The  only  water  supply  is  from  an  outdoor  hand-pump,  an  attic 
tank  and  a  ground  cistern,  the  latter  two  being  filled  only  by 
rain  and  both  dry  at  time  of  visit,  so  that  the  weekly  washing  had 
been  postponed  for  lack  of  water.  The  heating  facilities  are 
insufficient.  The  only  toilet  facilities  are  crude — ground  vaults 
in  outside  sheds.  Bathing  facilities  are  equally  primitive. 
Several  old  portable  iron  tubs  were  seen  in  various  parts  of  the 
institution;  one  partly  filled  with  rubbish,  one  turned  upside 
down,  and  none  showing  evidence  of  recent  use;  if  used,  the 
water  must  be  carried  by  hand,  all  hot  water  being  obtained  from 
the  kitchen  stove.  Under  the  circumstances,  it  is  perhaps  not 
surprising  that  there  was  reason  to  believe  that  at  least  some  of 
the  inmates  had  not  been  recently  bathed.  Straw  or  chaff  bed- 
ticks  are  used,  but  though  coarse,  the  bedding  was  clean.  Empty 
tin  cans  are  used  beneath  the  bed  legs  to  protect  the  floor. 

A  small,  single-story,  detached  building  is  known  as  the  "mad- 
house," and  is  in  charge  of  an  imbecile  inmate.  The  yard  about 
this  building  is  enclosed  by  a  rough,  whitewashed  board  fence, 
and  contains  the  usual  ground  vault  toilet,  with  an  old  rusted 
iron  bathtub,  in  an  old  shed  of  unpainted  boards.  This  building 
is  in  worse  condition  than  the  main  one  and  rubbish  was  every- 
where in  evidence,  papers,  sticks  and  boxes  being  scattered  in- 
doors and  outdoors,  while  the  beds  and  bedding  were  dirty  and 
disordered.  It  is  heated  by  an  old  battered  coal  stove.  A  few 
broken  chairs  and  a  bare  table  constitute  the  only  furniture. 
There  are  several  small  cell-like  rooms,  with  no  outside  windows, 
formed  by  whitewashed  board  partitions  and  with  the  upper  half 
of  the  doors  set  with  whitewashed,  wooden  slats. 

The  steward  and  his  wife,  the  matron,  are  the  only  inside  em- 
ployees, so  that  the  inmates  can  receive  little  personal  attention. 
In  the  "mad-house,"  aside  from  the  imbecile  in  charge,  two  male 
idiots  were  found,  an  epileptic  dement,  and  an  advanced  paretic; 

[72] 


the  latter  two  were  in  bed,  although  fully  dressed,  even  to  their 
shoes.  The  paretic  was  found  in  one  of  the  small,  unlighted  rooms, 
because,  it  was  said,  of  his  untidy  habits,  and  he  was  in  a  state  of 
personal  uncleanliness  when  seen. 

While  primarily  for  men,  the  "mad-house,"  being  the  only 
available  place  in  which  to  segregate  mental  cases,  it  was  neces- 
sary recently  to  confine  an  epileptic  girl  there  when  she  became 
excited  following  convulsions.  She  was  restrained  with  hand- 
cuffs and  locked  in  one  of  the  small  rooms,  despite  the  presence 
of  male  inmates  in  the  adjoining  small  rooms,  it  being  remembered 
that  the  upper  halves  of  the  doors  are  provided  with  open  slats. 
Her  cries  and  screams  are  said  to  have  been  so  constant  and  so 
loud  that  she  disturbed  not  only  everybody  in  the  "mad-house," 
but  in  the  main  building,  some  distance  away.  Her  hands  be- 
came much  swollen  in  her  effort  to  break  down  the  door,  and 
scars  from  the  handcuffs  were  perceptible  at  the  time  of  the  visit. 

The  separation  of  the  sexes  is  poor.  While  the  male  and  the 
female  inmates  live  on  opposite  sides  of  the  main  building,  the 
doors  open  directly  from  one  side  to  the  other  and  women  in- 
mates were  found  doing  the  housework  on  the  male  side,  with  some 
of  the  men  still  on  the  ward,  although  no  employee  was  present. 

An  hallucinatory  woman  lives  with  the  other  inmates,  receiving 
no  special  attention.  There  is  little  medical  attention,  the  visit- 
ing physician  only  responding  as  the  steward,  a  former  tanner, 
deems  necessary.  The  practice  of  the  County  of  purchasing 
morphine  for  two  morphine  habitues  is  at  least  of  questionable 
propriety. 

INSTITUTION  No.  40 

This  institution  is  housed  in  two  old  buildings,  one  erected  in 
1800  and  the  other  in  1855.  The  board  floors  are  worn  and 
broken,  the  plaster  is  cracked,  smoked,  and  has  fallen  off  in  places, 
while  the  woodwork  is  almost  devoid  of  paint  and  the  buildings 
generally  are  in  a  dilapidated  condition.  They  have  been  con- 
demned by  several  grand  juries,  but  only  recently  was  an  option 
obtained  on  a  site  for  a  new  institution.  However,  a  factional, 
political  fight  has  developed,  and  it  appears  probable  that  no 
improvement  in  conditions  can  be  expected  in  the  near  future. 

Part  of  two  dark  hallways,  with  rooms  on  either  side,  are  each 
reserved  as  a  so-called  "insane  ward."  They  are  shut  off  from 

[73] 


the  remainder  of  the  halls  by  partitions  of  turned  wood  bars. 
On  one  side  of  each  hall  is  a  bare  room  with  a  board  table  and 
backless  wooden  benches  which  serves  for  a  dining-room.  All 
the  appointments  are  meager  and  crude.  Opposite  each  such 
dining-room  is  a  toilet  section,  with  a  slop  sink  in  lieu  of  a  wash- 
basin. All  the  toilet  facilities  are  old,  worn,  and  unsanitary, 
and  they  are  insufficient  in  number. 

The  fire  protection  is  especially  poor,  and  loss  of  life  appears 
inevitable  in  case  of  fire.  The  sewage  flows  untreated  into  a 
creek  less  than  three  hundred  yards  from  the  buildings. 

In  spite  of  these  distressing  material  conditions,  it  is  a  pleasure 
to  note  the  prevalence  of  a  spirit  of  kindness  and  as  much  per- 
sonal attention  as  is  possible  with  a  single  attendant  for  each  of 
the  two  "insane  wards."  Nevertheless,  it  would  be  difficult  to 
imagine  a  picture  more  dismal  than  is  presented  by  the  poorly 
lighted,  bare,  and  dilapidated  wards  with  patients  sitting  idly 
on  benches  ranged  on  either  side,  where  they  spend  most  of  their 
waking  hours.  Aside  from  the  actual  insane  inmates  in  the 
"insane  wards,"  there  are  twenty-one  idiots  and  imbeciles 
confined  there.  There  is  poor  separation  of  the  sexes  whenever 
inmates  leave  the  wards,  and  on  such  account  the  presence  of  a 
sixteen-year-old  girl  imbecile,  who  is  extremely  erotic,  and  who 
has  had  a  child  following  incestuous  relations,  is  a  distinct  menace. 

This  institution  is  wholly  unfit  for  the  care  of  any  class  of  de- 
pendent human  beings. 

INSTITUTION  No.  41 

The  material  conditions  here  are  defective,  even  for  sane 
paupers.  A  so-called  "bull  pen"  is  a  locked  dormitory  where 
eight  inmates  were  found,  one  nude,  and  all  in  a  state  of  personal 
uncleanliness.  The  air  was  heavy  with  the  odor  of  a  deodorizing 
agent,  it  being  said  that  otherwise  it  would  be  impossible  to  re- 
main in  the  room.  The  fire  risk  is  great,  despite  which  inmates 
are  allowed  to  smoke  on  the  second  floor. 

Cases  of  alleged  insanity  are  brought  here  pending  commit- 
ment, but  the  two  cases  now  here  have  never  been  committed 
and  as  they  are  quiet  are  treated  as  the  other  inmates. 

The  only  provisions  for  the  insane  are  so-called  "cells,"  three 
of  which  are  located  in  the  basement  and  are  no  longer  used. 
The  latter  are  heavily  barred  with  iron  bars  over  a  single  high  base- 

[741 


merit  window;  are  provided  with  heavy  double  doors  which  open 
into  the  cellar,  while  the  walls  are  of  stone  construction.  A 
single  winding  wooden  stairway  leads  from  the  cellar  to  the  floor 
above,  so  it  would  appear  that  the  fire  risk  alone  should  have  pre- 
vented their  construction. 

The  cells  now  used  for  the  insane  are  rooms  set  apart  in  the 
almshouse  proper;  each  has  a  single  window,  heavily  guarded 
by  inside  iron  bars,  while  a  "strong  cell"  has  also  iron  bars  out- 
side the  window.  Heavy  double  doors  are  provided,  the  inner 
one  being  heavily  bound  with  iron  braces ;  they  have  an  aperture 
in  the  center  with  an  inside  shelf,  where  food  is  placed  by  the 
pauper  inmate,  who  alone  cares  for  the  insane  patients.  The 
cells  have  no  furnishings  except  a  mattress  and  a  blanket  thrown 
on  the  floor,  except  in  a  single  instance,  where  a  small  cot  is  pro- 
vided. A  tin  bucket  is  the  only  toilet  convenience.  As  there  is 
but  one  cell  on  the  women's  side,  it  occasionally  happens  that 
women  are  placed  in  the  men's  cells,  and  it  was  said  that  male 
paupers  have  used  the  door  aperture  to  inspect  the  insane  women. 

The  pauper  assigned  to  care  for  the  male  insane  is  a  cripple, 
and  is  physically  unable  to  cope  with  an  excited  case,  but  if  he 
deems  it  necessary  to  enter  the  cell  of  an  excited  patient  he  calls 
to  his  aid  a  sufficient  number  of  other  inmates  to  subdue  the 
patient  by  force  of  numbers.  There  are  no  bathing  facilities, 
and  while  it  was  not  admitted  that  insane  patients  never  bathe, 
the  informant  remarked :  "You  can  form  your  own  conclusions." 
He  added:  "If  they  are  not  insane  when  they  come  here,  this 
place  will  make  them  so." 

All  alleged  cases  of  insanity  are  locked  in  cells,  because  the 
local  authorities  do  not  feel  that  they  can  afford  to  take  chances, 
since  a  case  committed  suicide  several  years  ago  and  there  have 
been  several  attempts  since.  While  cases  are  sometimes  com- 
mitted and  removed  within  a  week,  it  was  said  that  if  they  have 
no  friends  to  secure  a  lawyer  to  hasten  proceedings,  "They  lay 
here  the  limit,"  and  have  been  locked  in  a  cell  for  as  long  as  two 
months  without  once  leaving  it. 

The  visiting  physician  has  no  responsibility  for  the  insane, 
except  as  his  attention  may  be  called  to  them  by  the  steward  for 
the  care  of  physical  ills. 

The  situation  is  made  worse  by  the  fact  that  within  less  than 
fifteen  miles  is  a  State  hospital,  where,  with  excellent  natural 

I  751 


advantages  and  good  material  conditions,  only  such  insane  can 
be  received  as  are  regarded  as  chronic  and  who  are  transferred 
from  other  institutions  for  the  insane.  If  the  State  hospital 
were  allowed  to  receive  new  admissions  from  the  surrounding 
community,  the  above  conditions  would  soon  cease  to  exist, 
simply  from  lack  of  necessity.  A  better  illustration  could  not 
be  presented  of  the  results  attending  the  lack  of  a  general  policy 
governing  the  State  as  a  whole  than  the  existence  side  by  side, 
within  a  few  miles  of  each  other  of  such  extremes  in  standards 
of  care. 

INSTITUTION  No.  42 

This  is  an  almshouse  of  the  better  type  and,  in  general,  for  an 
almshouse,  the  physical  conditions  are  satisfactory.  But  a 
single  insane  patient  was  found  among  the  inmates  and  only  rarely 
are  patients  brought  here  pending  commitment.  There  is  a 
single  cell  provided  in  the  basement  for  the  violent  insane,  which, 
however,  is  said  not  to  have  been  used  for  about  a  year.  It 
has  a  single,  small,  high,  basement  window,  with  a  small  grated 
aperture  in  the  center  of  a  solid  wooden  door.  It  is  so  dark  that 
one  cannot  see  across  it  through  the  open  doorway.  It  is  padded, 
both  as  to  floor  and  side  walls,  and  is  devoid  of  furnishings  of 
any  kind.  The  reason  for  alleged  cases  not  having  been  brought 
here  recently  is  that  they  are  more  frequently  taken  to  the  County 
jail. 

INSTITUTION  No.  43 

This  is  the  smallest  almshouse  visited,  being  maintained  by  a 
special,  small  Poor  District.  No  cases  of  insanity,  as  such,  are 
ever  brought  here,  but  three  women  inmates  were  found  present- 
ing definite  evidence  of  insanity.  All  were  unattended  in  their 
rooms.  One  was  restless,  walking  up  and  down,  talking  to  her- 
self, and  rubbing  her  face  and  neck,  upon  which  were  numerous 
abraded  areas  thus  produced. 

INSTITUTION  No.  44 

This  is  one  of  the  better  almshouses,  and  except  that  the  build- 
ings show  age,  the  physical  conditions  are  satisfactory  for  aims- 
house  inmates.  Few  cases  of  alleged  insanity  are  brought  here 
and  none  are  supposed  to  be  here  at  present,  although  six  cases 
were  found  presenting  definite  evidence  of  insanity.  The  prac- 

[76] 


tice  of  keeping  the  alleged  insane  here  has  only  ceased  since  the 
opening  of  a  State  hospital  in  the  vicinity,  since  which  time  direct 
commitments  from  homes  are  usual.  Thus  is  shown  the  benefit 
to  a  community  of  a  modern  hospital  for  the  insane. 

There  are  four  so-called  cells  for  the  insane,  which,  since  the 
practice  of  bringing  insane  patients  here  has  largely  ceased,  are 
used  for  the  punishment  of  inmates.  They  are  ordinary  rooms 
with  iron-barred  windows,  and  an  open  toilet  hopper  in  one 
corner,  and  while  two  have  ordinary  wooden  doors,  substituted 
at  the  steward's  initiative  for  the  original  open  iron-barred  doors, 
the  latter  still  remain  on  the  other  two  cells.  When  occupied, 
the  doors  are  kept  locked,  food  being  passed  through  an  opening 
in  the  iron  grating. 

INSTITUTION  No.  45 

This  is  another  almshouse  with  fairly  good  physical  conditions 
for  the  care  of  paupers.  No  cases  of  insanity  are  supposed  to  be 
kept  here,  nor  have  any  alleged  cases  been  sent  here  for  observa- 
tion for  some  years.  However,  six  cases  were  found  presenting 
definite  evidence  of  insanity,  aside  from  deterioration,  which 
is  present  in  a  large  number;  most  of  these  cases  have  persecu- 
tory  ideas,  thus  rendering  them  a  source  of  annoyance  to  the 
other  inmates.  One  involutional  case  remains  mute  for  days, 
when  she  breaks  forth  into  loud  waitings  and  meanings,  which 
she  keeps  up  incessantly  for  long  periods.  At  such  times  she  is 
locked  in  a  cell,  and  although  such  treatment  is  said  to  quiet  her 
within  twenty-four  hours,  it  is  difficult  to  understand  how  this 
result  is  effected,  except  by  exhaustion. 

The  cell  mentioned  is  located  in  a  basement  against  a  hillside ; 
there  is  a  single,  small,  high  window  about  10  x  18  inches  opening 
on  a  narrow  shaft  and  hence  both  light  and  ventilation  are  very 
poor.  It  is  so  dark  that  little  of  the  interior  can  be  seen  by  look- 
ing through  the  iron-barred  door  which  opens  on  a  narrow  pas- 
sageway. There  are  no  toilet  facilities  and  the  cell  is  bare  of 
furnishings.  As  it  was  remarked:  "They  dread  the  locked 
door."  A  further  remark  illustrates  the  prevailing  punitive 
idea:  "You  have  to  show  them  who  is  boss." 

Tubercular  cases  are  received  here,  as  in  most  of  the  other 
almshouses,  none  of  which  have  proper  facilities  for  isolation. 

I  771 


INSTITUTION  No.  46 

For  the  most  part,  the  material  conditions  are  fairly  good  for 
almshouse  purposes,  in  many  respects  being  above  the  usual 
almshouse  standard.  This  applies  especially  to  the  service  de- 
partments, farm,  etc. 

Alleged  cases  of  insanity  are  brought  here  pending  commit- 
ment, but  the  insane  inmates  now  here  are  regarded  and  treated 
like  all  the  other  inmates.  Up  to  a  year  ago  disturbed  insane 
patients  were  confined  in  a  steel  cage  formed  of  flat  steel  bars 
arranged  in  a  lattice-work.  This,  located  in  the  basement,  is 
divided  into  two  compartments  by  a  blank  partition,  so  that  two 
persons  can  be  confined  at  once,  and  in  the  past  even  patients  of 
the  opposite  sex  are  said  to  have  thus  been  confined  together. 
The  use  of  the  cage  is  now  deemed  inhumane,  it  being  used  now 
only  to  punish  refractory  pauper  inmates.  The  disturbed  in- 
sane are  now  confined  in  a  cell,  which  is  merely  a  cellar  room  with 
whitewashed  brick  walls  on  three  sides  and  a  board  partition  on 
the  fourth  side.  It  is  at  least  two-thirds  below  the  ground  level, 
with  a  single,  small,  high,  basement  window  covered  with  heavy 
wire  grating.  The  room  is  of  good  size,  but  is  damp,  and  there 
is  no  ventilation,  with  the  door  and  window  closed.  It  is  pro- 
vided with  a  single  exposed  electric-light  globe,  which  can  be 
reached  by  a  patient  standing  on  the  bed,  and  when  this  fact 
was  pointed  out  the  superintendent  remarked  that  it  was  fortu- 
nate a  suicidal  patient  confined  here  last  winter  had  not  used  the 
globe  in  a  suicidal  effort.  A  bed  and  a  bucket  for  toilet  facilities 
constitute  the  only  furnishings.  There  is  a  door  of  iron  grating, 
with  a  heavy,  solid,  wooden  door  outside.  Both  doors  are  locked 
when  the  cell  is  occupied  "to  shut  out  the  noise."  While  it  does 
appear  that  the  cell  is  slightly  less  objectionable  than  the  steel 
cage,  yet  it  is  anomalous  that  it  should  be  regarded  as  an  advance 
in  the  humane  treatment  of  the  insane. 

One  of  the  insane  women  now  here  becomes  talkative  and  dis- 
turbed at  intervals,  so  it  is  thought  it  will  eventually  be  necessary 
to  commit  her;  but  the  others  are  quiet  and  no  such  action  is 
probable  in  their  cases.  One  of  the  women  defectives  has  a  child, 
the  father  of  whom  is  a  vagrant,  formerly  an  inmate. 


INSTITUTION  No.  47 

This  almshouse  is  satisfactory  for  the  care  of  pauper  inmates. 
No  insane  are  supposed  to  be  kept  here  and  but  two  insane 
cases  were  found.  Through  the  efforts  of  a  progressive  visiting 
physician  cases  of  alleged  insanity  are  rarely  brought  here  pend- 
ing commitment,  although  two  women  were  committed  from  here 
during  the  past  year,  one  after  a  month  and  the  other  after  two 
months'  residence;  as  they  were  quiet  they  were  allowed  to 
mingle  with  the  other  inmates,  receiving  no  special  attention. 

Formerly  when  it  has  been  necessary  to  care  for  disturbed 
insane,  the  women  have  been  locked  in  a  narrow  hallway  outside 
the  bath  and  toilet  rooms,  all  doors  opening  on  which  are  of 
heavy,  solid,  wooden  construction.  This  hallway  is  short,  has 
a  single  window,  with  an  inside,  heavy,  solid  wooden  shutter, 
which  it  has  been  customary  to  close  when  patients  were  placed 
here.  Although  artificial  light  is  provided,  no  ventilation  is 
possible  under  such  conditions.  This  hallway,  being  the  only 
means  of  reaching  the  toilet  and  bathroom,  has  had  to  be  tra- 
versed when  patients  wish  to  reach  the  latter,  thus  disturbing  the 
insane  inmate  here  confined. 

On  the  men's  side  there  is  a  special  room  for  insane  cases,  which 
has  been  finished  off  with  wooden  boards  covering  the  entire  side 
walls.  It  has  a  single  window,  inside  of  which  is  a  solid,  heavy, 
wooden  shutter.  The  door  is  constructed  of  wire  grating,  covered 
on  the  outside  with  a  layer  of  boards.  With  the  door  and  shutter 
shut,  there  is  no  ventilation.  It  is  a  pleasure  to  note  that  the 
steward  stated  he  would  only  use  this  room  and  the  hallway  in 
case  of  extreme  necessity. 

INSTITUTION  No.  48 

The  material  conditions  here  are  satisfactory  for  an  alms- 
house.  Although  this  institution  is  supposed  to  have  no  insane, 
the  local  authorities  recognize  the  insanity  of  the  insane  persons 
found  among  the  inmates,  it  being  explained  that  so  long  as  the 
insane  are  quiet  and  inoffensive  it  is  customary  to  keep  them 
here,  regardless  of  mental  symptoms,  as  the  County  thereby 
saves  the  extra  expense  involved  in  their  maintenance  in  a  State 
hospital.  However,  when  one  becomes  noisy  or  troublesome, 
commitment  follows.  One  such  case  had  an  incised  wound,  the 
result  of  striking  his  head  on  a  washbowl,  when,  in  a  fit  of  anger, 

l79l 


he  declared  he  would  kill  himself,  and  it  is  felt  that  this  individual 
may  shortly  have  to  be  committed. 

Five  of  the  defective  women  inmates  have  borne  children, 
although  but  two  are  married,  and  their  husbands  have  deserted. 
One  has  her  child  with  her.  A  male  sane  inmate  was  seen  bring- 
ing in  a  basket  of  potatoes,  although  his  nose  was  partly  eaten 
away  with  carcinoma  and  there  was  no  dressing  upon  it. 

Alleged  cases  of  insanity  are  brought  here  pending  commit- 
ment. When  disturbed  they  are  kept  in  so-called  cell  rooms, 
there  being  four  for  the  men  and  three  for  the  women.  The  men's 
rooms  are  ordinary  rooms,  but  have  tile  floors;  each  has  an 
outside  window  covered  with  a  close  iron-bar  mesh-work,  with 
an  inside  door  of  similar  construction,  outside  of  which  is  a  heavy, 
solid,  wooden  door.  Both  doors  are  kept  locked  when  the  rooms 
are  in  use.  The  women's  cell  rooms  are  inside,  with  no  opening 
other  than  the  door,  and  hence  are  dark  and  poorly  ventilated. 
The  side  walls  are  finished  with  boards ;  the  doors  are  of  heavy, 
wooden  construction,  with  a  central  aperture  covered  with 
straight,  heavy,  iron  bars.  The  rooms  are  heated  only  from 
the  hallways.  The  only  toilet  facilities  provided  are  small 
vessels.  On  the  day  of  the  visit  but  one  cell  was  occupied  and 
that  by  a  male,  restless,  deteriorated  epileptic. 

While  unused,  two  so-called  "standing  cells"  are  an  interesting 
relic  of  the  past;  they  are  merely  two  small  closets,  just  large 
enough  for  an  adult  to  stand  erect  in  with  the  door  closed.  If 
a  person  once  sank  down,  it  would  thus  be  impossible  to  again 
assume  an  erect  posture ;  it  was  admitted  that  the  quieting  effect 
of  such  confinement  could  only  have  resulted  from  exhaustion, 
and  it  was  said  that  their  manifest  barbarity  caused  their  aban- 
donment. 

SUMMARY  OF  UNLICENSED  ALMSHOUSES 

In  reviewing  this  group  of  almshouses  it  may  be  said  that,  while 
the  majority  provide  fair  material  conditions  for  paupers,  even 
that  is  not  true  of  all  of  them,  and  none  have  any  proper  means 
of  caring  for  the  insane.  Despite  this  fact,  three  of  them  have 
locally  recognized  insane  departments.  None  of  the  local  au- 
thorities have  any  idea  as  to  what  constitutes  proper  treatment 
for  the  insane,  and  there  can  be  no  doubt  that  many  insane 
patients  have  failed  of  recovery,  even  if  some  alleged  cases  of 

[80] 


insanity  have  not  been  rendered  actually  insane,  by  the  barbarous 
treatment  to  which  they  have  been  subjected.  In  such  category 
may  be  mentioned  seclusion  for  long  periods  in  dark  and  un- 
wholesome cells,  in  some  instances  cared  for  only  by  pauper  in- 
mates, and  often  deprived  of  even  the  most  common  and  most 
necessary  conveniences  of  life.  Treated  more  as  wild  animals 
than  as  unfortunate  human  beings  entitled  to  every  considera- 
tion and  sympathy,  they  constitute  a  class  of  individuals  for 
whom  no  possible  future  misfortune  can  have  any  terrors. 

Fortunately  the  number  of  the  insane  in  the  almshouses  is 
comparatively  small,  but  so  long  as  Counties  act  independently 
in  caring  for  this  dependent  class,  so  long  will  there  be  some  Coun- 
ties in  which  a  patient  must  be  either  "noisy  or  troublesome"  to 
receive  the  benefit  of  treatment  in  a  State  hospital,  the  matter  of 
cost  outweighing  the  possibility  of  cure  in  quiet,  inoffensive  cases. 


GENERAL  SUMMARY 

In  reviewing  the  State  as  a  whole,  as  to  the  care  of  the  insane, 
a  striking  feature  is  the  great  variability  in  the  standard  of  care 
and  treatment  maintained  in  different  types  of  institutions,  and 
in  some  instances  in  different  institutions  of  the  same  type.  In 
some  places  patients  receive  every  care  and  attention  that  is  indi- 
cated by  modern  science  as  beneficial,  while  in  others,  although 
there  appears  no  evidence  of  any  degree  of  actual  physical  abuse, 
yet,  what  may  be  even  worse,  there  is  the  most  utter  neglect. 

It  appears  to  be  largely  a  question  of  the  geographical  location 
of  a  patient's  residence  whether  such  patient  receives  the  benefit 
of  active,  curative  treatment,  or  is  allowed  to  lapse  into  chronicity 
in  some  custodial  institution  without  an  effort  made  to  stay  the 
course  of  the  disease.  Just  how  our  boasted  political  equality 
can  be  reconciled  with  such  a  vital  inequality  of  opportunity  does 
not  appear.  There  is  no  greater  necessity  to  "the  pursuit  of 
happiness"  than  mental  health,  and  so  far  as  public  provisions 
are  made  for  the  insane  it  would  appear  as  though  one  citizen  had 
as  much  right  to  receive  good  treatment  and  a  chance  for  mental 
restoration  when  stricken  with  mental  disease  as  another. 

The  un-American  and  un-democratic  practice  prevailing  in  some 
communities  (Institutions  Nos.  19  and  27)  of  sending  patients  "  be- 
longing to  the  better  families  "  to  a  State  hospital  and  others  to  the 
6  [8iJ 


county  custodial  institution  should  no  longer  be  tolerated.  But 
it  is  in  no  way  worse  than  determining  the  question  as  to  where  a 
patient  shall  be  committed  by  the  degree  of  troublesomeness 
manifested,  regardless  of  prognosis.  It  is  impossible  that  the 
latter  can  be  adequately  taken  into  account  when  the  matter  is 
determined  by  County  Commissioners,  Poor  Directors  and  non- 
medical  stewards  and  superintendents  of  county  institutions,  as 
is  now  the  prevailing  practice,  even  in  communities  where  the 
loud  boast  is  heard  that  only  chronic  cases  are  sent  to  the  county 
institutions. 

That  varying  standards  should  exist  is  not  surprising  in  view 
of  the  varying  methods  of  dealing  with  the  insane.  There  can 
not  be  more  than  one  best  system,  and  but  a  single  policy  can  be 
successfully  followed.  The  only  results  obtained  in  the  State  of 
Pennsylvania,  which  have  been  even  approximately  satisfactory, 
have  been  in  the  State  hospitals.  The  fact  that  the  State  has 
never  yet  assumed  full  responsibility  for  the  insane  is  no  reason 
why  advantage  should  not  be  taken  of  experience.  The  mere 
fact  that  treatment  of  insanity  implies  deprivation  of  liberty 
suggests  the  propriety  of  general  laws  governing  all  details  of  the 
matter  applicable  in  exactly  the  same  manner  to  all  individuals 
affected  throughout  the  State. 

But  apart  from  the  desirability  of  securing  a  uniform  and  satis- 
factory standard  of  care  is  the  imperative  necessity  of  taking 
some  action  to  provide  for  the  excess  number  of  insane  in  the 
State  for  whom  there  are  now  no  accommodations  in  any  kind  of 
an  institution.  When,  as  has  happened,  a  city  and  a  State  hos- 
pital have  to  resort  to  the  courts  to  determine  the  right  of  each  to 
refuse  to  accept  more  patients  because  of  dangerous  overcrowding 
it  would  seem  as  though  a  definite,  well-planned  policy  should  at 
once  be  substituted  for  the  present  temporizing  method,  especially 
as  in  the  dispute  mentioned  the  fact  of  overcrowding  was  indis- 
putable, and  hence  both  institutions  were  justified  in  their  atti- 
tude. 

RELATIVE  MERITS  OF  STATE  AND  COUNTY  CARE 

In  discussing  the  relative  merits  of  State  and  county  care,  it 
must  be  admitted  that  the  latter  system  has  had  numerous  argu- 
ments urged  in  its  favor,  the  main  ones  being  as  follows: 

1.  Possibility  of  patients  remaining  near  home  and  receiving 
visitors. 

[82] 


2.  Greater  opportunity  for  occupation. 

3.  More  individual  care  and  avoidance  of  so-called  "massing 

together"  in  large  institutions. 

4.  More  homelike  surroundings  and  avoidance  of  institu- 

tional atmosphere. 

5.  Greater  numbers  of  recoveries. 

6.  Lower  maintenance  cost,  especially  for  chronic  insane. 
The  above  arguments  will  be  discussed  separately  and  in  order. 

1.  POSSIBILITY  OF  PATIENTS  REMAINING  NEAR  HOME 
AND  RECEIVING  VISITORS 

While  theoretically  visits  from  friends  may  be  more  readily 
possible  in  county  institutions,  as  a  matter  of  fact  they  are  not. 
Including  only  such  institutions  as  keep  records  of  visits  and 
those  in  which  the  local  authorities  felt  it  was  possible  to  make  an 
accurate  estimate,  it  was  found  that  in  six  State  hospitals,  with  a 
census  of  7275,  there  were  2942  patients  who  had  not  been  visited 
within  a  year,  while  in  21  city  and  county  institutions,  with  a 
census  of  6476,  there  were  2583  patients  who  had  not  been  visited 
within  a  year.  In  figuring  the  percentage  of  unvisited  patients, 
the  surprising  result  is  that  the  proportion  of  visited  patients 
remains  practically  constant,  regardless  of  the  type  of  institution 
— the  percentage  for  the  State  hospitals  being  40.43  per  cent  un- 
visited and  for  the  city  and  county  institutions  39.88  per  cent 
unvisited. 

It  is  contrary  to  ordinary  experience  to  believe  deprivation 
of  liberty  amid  familiar  scenes  is  less  irritating  than  the  loss  of 
liberty  amid  strange  ones.  Under  the  latter  circumstance  new 
surroundings  and  interests  are  often  found  to  so  occupy  even  a 
diseased  mind  that  such  deprivation  of  liberty  as  is  necessary 
is  obscured  and  unrealized  by  the  patient.  Such  result  cannot 
be  expected  when  confinement  occurs  amid  familiar  surround- 
ings, where  all  objects  recall  former  habits  of  unrestricted  move- 
ment. But  aside  from  the  above  consideration,  if  a  well  balanced 
State  Hospital  system  were  established,  with  due  regard  to  the 
distribution  of  population,  no  hardship  regarding  visits  need 

result. 

2.  GREATER  OPPORTUNITY  FOR  OCCUPATION 

The  matter  of  occupation  is  undeniably  of  first  importance. 
But  this,  like  all  other  features,  must  be  judged  by  general  results 

[83] 


and  not  by  isolated  instances.  The  degree  to  which  occupation 
is  developed  in  any  institution,  regardless  of  type,  depends  upon 
personal  initiative  and  material  conditions. 

The  actual  findings  respecting  this  matter  are  as  follows: 
8  State  hospitals  have  percentages  ranging  from  39.1  per  cent  to 
64.3  per  cent  of  the  total  hospital  population  regularly  occupied. 

Institution  No.  1 1 43.2  per  cent 

12 48.2 

13 42.1 

H 48.4 

15 39-i 

16 64.3 

17 61.8 

18 48.5 

The  hospital  (No.  15)  in  which  the  lowest  percentage  obtains  is 
termed  a  State  hospital  by  courtesy  only,  for,  while  supported  for 
the  most  part  by  State  funds,  it  is  under  private  control.  While, 
as  is  to  be  expected,  the  above  percentages  show  some  variation, 
and  the  number  of  patients  occupied  in  some  institutions  could 
undoubtedly  be  increased,  the  general  average  is  good. 

As  for  the  19  county  institutions,  the  following  indicates  the 
percentage  of  the  total  number  of  patients  regularly  employed : 

Institution  No.  19 29.2  per  cent 

20 28.8    ' 

21 50.7    ' 

22 "  I  or  2  patients" — has  cen- 
sus of  but  8  patients 

23 57.4  per  cent 

24 26.8    ' 

25 46.1    ' 

26 "  About  50  per  cent 

27 40.9  per  cent 

28 36.9    ' 

29 52.1    ' 

30 49-9    ' 

31 50-3    ' 

32 "  About  50  per  cent 

33 67.2  per  cent 

34 43-5    ' 

35 25.6    "      " 

36 32.0    ' 

37 39-2    ' 

The  percentages  given  show  a  much  wider  range  of  variability 
in  the  number  of  patients  occupied  in  the  county  institutions 
than  in  the  State  hospitals,  suggesting  that  when  good  results  are 
obtained  in  the  former  it  is  because  of  special  local  conditions  or 
special  initiative.  The  latter  is  especially  true  in  Institutions  Nos. 

[84] 


21,  23,  29  and  33,  where  has  occupation  been  developed  in  an 
excellent  manner,  although  in  the  first  mentioned  under  most  ad- 
verse circumstances.  The  lesson  to  be  drawn  is  not  that  either 
State  or  county  institutions,  as  such,  offer  superior  opportunity 
for  occupational  work,  but  rather  that  opportunity  can  be  offered 
in  any  type  of  an  institution  if  properly  equipped  and  provided 
with  sufficient  acreage.  The  two  factors  mentioned — material 
conditions  and  personal  initiative,  are  alone  essential  to  success, 
and  the  mere  fact  that  fairly  uniform  results  are  obtained  in  the 
State  hospitals,  whereas  county  institutions  show  a  wide  vari- 
ability, seems  to  indicate  that  such  factors  are  more  apt  to  exist 
in  State  hospitals. 


3.  MORE  INDIVIDUAL  CARE  AND  AVOIDANCE  OF  SO-CALLED 
"MASSING  TOGETHER"  IN  LARGE  INSTITUTIONS 

The  lack  of  individual  care  in  the  State  hospitals  has  not,  at 
the  present  time  at  least,  assumed  the  proportions  of  such  lack 
in  county  institutions.  This  fact  is  demonstrated  by  the  num- 
ber of  attendants  found  on  duty  in  the  various  institutions  in 
proportion  to  the  number  of  patients  treated  therein.  The 
number  actually  on  duty  is,  of  course,  less  than  the  number 
assigned,  as  there  are  always  a  certain  number  of  absences  by 
reason  of  sickness,  regular  time  allowance  off  duty,  special  de- 
tails, etc. 

In  the  State  hospitals  the  proportion  of  day -attendants  was 
as  follows: 

Institution  No.  n I  attendant  to  14  patients 


12. 

13 
14. 

15- 
16. 

17 

18. 


13 
12 

13 
II 
16 
13 
19 


The  last  institution  is  for  criminal  insane  only  and  the  propor- 
tion of  attendants  is  there  less  because  of  the  closer  confinement 
of  patients  and  the  necessity  for  a  large  night  force,  the  latter 
being  in  the  proportion  of  I  attendant  to  17  patients. 

The  proportion  of  day-attendants  in  the  county  hospitals  was 
as  follows: 

[85] 


19  

i 

2O  

i 

21  

i 

22  

IN 

23  

i 

24  

i 

25  

i 

26  

i 

27  

i 

28  

i 

29  

,  i 

30  

i 

31  

i 

32  

i 

33  

i 

34  

i 

35  

i 

36  

i 

37  

i 

24 

16 

None,  solely  for  8  insane 
here  confined 

21  p 
22 
26 
14 

22 
23 
17 
22 

16 

15 
18 

19 
13 

21 

32 

'In  some  instances  the  difference  in  proportion  between  the 
State  hospitals  and  county  institutions  is  not  large,  but  as  seen 
from  the  details  of  the  care  given,  as  set  forth  in  this  report,  the 
type  of  care  in  the  county  institutions,  considering  the  whole 
system,  is  so  decidedly  inferior  to  that  in  the  State  hospitals  as 
to  admit  of  no  comparison.  In  general,  it  is  the  substitution  of 
mechanical  means  of  restraint  and  confinement  for  personal  care 
and  attention,  the  lesser  cost  of  the  former  no  doubt  being  a  factor. 

The  difference  between  the  State  hospitals  and  County  institu- 
tions is  still  more  marked  as  regards  medical  care  and  attention. 
While  all  State  hospitals  have  staffs  of  resident  physicians,  the 
number  of  physicians  being  in  fair  proportion  to  the  number  of 
patients  treated,  in  but  8  of  the  19  County  hospitals  are  there 
resident  physicians.  In  4  County  hospitals,  or  half  of  those 
having  resident  physicians,  there  is  but  a  single  physician  in  the 
person  of  a  medical  superintendent,  or  a  physician  in  charge,  who 
in  every  instance  is  obliged  to  devote  so  much  of  his  time  to 
executive  duties  that  it  is  impossible  for  him  to  give  as  much 
attention  to  strictly  medical  matters  as  would  appear  desirable. 
In  the  remaining  4  County  institutions  with  resident  physicians, 
in  no  instance  are  there  more  than  two  assistant  physicians  in 
addition  to  the  physician  in  charge,  although  such  institutions 
have  the  number  of  patients  indicated  below : 

No.  20,  census  886 
No.  30,  517 

No.  32,  621 

No.  35,       "      456 
[86] 


In  the  II  County  hospitals  without  a  resident  physician,  the 
only  medical  attention  is  that  given  by  visiting  physicians  who 
regularly  visit  only  at  intervals  of  varying  length.  It  is  thus  not 
surprising  to  find  that  the  medical  work  is  devoted  solely  to  the 
treatment  of  physical  ills. 

As  to  "massing  together,"  no  properly  equipped  hospital  of 
any  character  allows  such  conditions  to  exist.  A  large  institu- 
tion does  not  necessarily  mean  such  a  single,  monasterial  structure 
as  was  formerly  in  vogue,  but  a  collection  of  numerous  building 
units,  sometimes  widely  separated.  With  the  modern  cottage 
system,  a  large  institution  alone  is  able  to  provide  proper  classi- 
fication, a  general  lack  of  which  is  one  of  the  serious  faults  of  the 
county  institutions.  Indeed,  the  only  classification  attempted  in 
the  vast  majority  of  them  is  to  separate  the  disturbed  from  the 
quiet  as  well  as  may  be,  but  that  such  result  is  not  always  ob- 
tained is  shown  in  the  main  body  of  this  report.  It  is  likewise 
there  shown  that  the  close  physical  contact  between  patients 
of  many  different  types  could  not  be  exceeded  under  any  possible 
condition  of  "massing  together"  in  a  State  hospital. 

4.    MORE  HOME-LIKE  SURROUNDINGS  AND  AVOIDANCE  OF  THE 

INSTITUTIONAL  ATMOSPHERE 

The  less  said  about  the  home-like  surroundings  the  better, 
so  far  as  the  average  county  institution  is  concerned,  for  it  may  be 
again  repeated  that  average  conditions  must  be  considered  and 
not  specific  instances.  And  the  prevailing  custom  of  erecting  the 
buildings  for  the  insane  at  the  rear  of  the  almshouse  buildings 
is  certainly  not  calculated  to  remove  institutional  atmosphere. 
Neither  is  the  practice  peculiar  to  county  institutions  for  the 
insane  of  providing  only  enclosed  exercise  yards,  most  of  which 
are  surrounded  by  high  fences,  completely  cutting  off  the  pa- 
tients' view. 

5.  GREATER  NUMBER  OF  RECOVERIES 

It  has  been  argued  that  the  county  hospitals  cure  more  pa- 
tients than  do  the  State  hospitals.  If  such  were  the  case,  it 
would  seem  that  all  progress  has  been  made  under  false  im- 
pressions. If  poor  facilities  and  lack  of  facilities  produce  better 
results  than  do  proper  provisions,  then,  indeed,  should  present 
conditions  prevail. 

[87] 


It  would  be  possible  to  present  statistics  as  to  recoveries  which, 
as  in  the  statistics  given,  would  show  individual  county  institu- 
tions making  a  good  showing,  but  as  the  manner  by  which  re- 
coveries have  been  determined  leaves  much  to  be  desired,  such 
statistics  would  prove  nothing.  For  instance,  even  in  such 
county  institutions  as  have  a  physician  to  determine  the  ques- 
tion of  recovery,  it  was  found  that  patients  were  discharged  as 
recovered  when  diagnosed  as  suffering  from  incurable  disorders, 
such  as  paranoia,  and  even  the  fatal  disease  of  paresis.  In  one 
institution  with  a  high  recovery  rate  it  was  found  that  33  per 
cent  of  the  recoveries  were  alcoholic  cases,  some  of  whom  were 
admitted  and  discharged  several  times  within  the  year,  each  time 
counting  as  a  recovery,  one  such  case  repeating  on  four  different 
occasions.  Recovery  rates  prepared  in  such  a  manner  are  not  to 
be  considered  seriously.  Nor  can  it  be  thought  that  in  such 
institutions  as  provide  a  layman  to  pass  on  the  question  of  re- 
covery, recovery  statistics  are  any  more  accurate. 

The  question  of  recovery  is  ofttimes  most  difficult  to  deter- 
mine. Insanity  is,  after  all,  a  social  maladjustment,  and,  unless 
a  patient  has  had  an  opportunity  to  prove  recovery  by  proper 
social  adjustment  outside  an  institution,  statistics  bearing  on  the 
subject  are  more  apt  to  lead  to  erroneous  conclusions  than  correct 
ones.  Hence  the  desirability  of  a  parole  period  with  subsequent 
examination  prior  to  discharge.  Despite  all  the  above,  7  of  the 
19  county  institutions  discharged  no  cases  as  recovered  during 
their  last  hospital  year,  5  institutions  discharged  in  the  aggre- 
gate 1 8  cases  as  recovered,  while  in  but  7  were  there  fair  re- 
covery rates,  assuming,  for  the  sake  of  argument,  that  statistics 
were  accurately  prepared.  In  the  State  hospitals,  on  the  con- 
trary, normal  recovery  rates  everywhere  obtained,  except  only 
as  they  were  influenced  by  their  special  character,  as  in  the  State 
hospital  for  chronic  insane  and  the  State  hospital  for  criminal 
insane. 

6.  LOWER  MAINTENANCE  COST,  ESPECIALLY  FOR  CHRONIC  INSANE 
It  cannot  be  denied  that  cost  of  maintenance  is  less  in  county 
hospitals,  as  proper  facilities  cost  more  than  does  their  lack. 
Mere  custodial  care  costs  less  than  does  remedial  medical  treat- 
ment. An  article  of  poor  quality  can  always  be  purchased  for 
less  than  a  superior  one.  It  is  cheaper  to  die  without  medical 

f881 


attendance  than  with  it.  But  because  these  facts  are  true,  no 
one  suffering  from  even  a  fatal  illness,  or  with  a  near  relative  so 
suffering,  would  feel  that  the  question  of  cost  should  prevent  the 
sufferer  from  receiving  every  possible  medical  aid  and  atten- 
tion. Therefore,  it  appears  strange  that  mental  death,  in  many 
respects  worse  than  physical  death,  should  be  differently  re- 
garded. 

But  it  is  argued  that  chronic  insane  require  only  custodial 
care.  The  first  difficulty  is  to  find  the  person  competent  to 
determine  chronicity;  while,  of  course,  it  is  possible  to  do  so  in 
many  cases,  there  are  still  many  others  in  which  present  knowl- 
edge does  not  allow  a  definite  statement.  No  better  proof  of 
this  is  needed  than  the  fact  that  there  were,  during  the  last  hos- 
pital year  of  the  various  institutions,  117  patients  discharged  as 
recovered  who  had  been  under  treatment  longer  than  a  year. 
After  making  due  allowance  for  such  inaccuracies  in  the  sta- 
tistics as  have  been  pointed  out,  the  above  renders  striking  con- 
firmation of  the  fact,  repeatedly  demonstrated  by  experience,  that 
in  some  forms  of  insanity  improvement  and  even  recovery  may 
occur  after  several  years'  duration.  It  is  therefore  not  creditable 
that  the  question  of  cost  should  be  allowed  to  weigh  against 
every  possible  chance  being  offered  every  insane  person  for  mental 
restoration. 

It  is,  however,  unfortunately  true  that  large  numbers  of  the  in- 
sane cannot  be  restored  by  any  known  means  of  treatment,  but 
that  does  not  argue  that  they  are  not  entitled  to  the  best  grade 
of  custodial  care  consistent  with  a  properly  economical  ad- 
ministration. The  details  already  presented  relative  to  indi- 
vidual institutions  indicate  that  even  custodial  care,  as  such, 
is  best  given  in  the  State  hospitals,  for,  with  detached  groups  of 
buildings,  no  need  arises  whereby  such  patients  come  in  contact 
with  acute  patients.  Furthermore,  it  is  not  often  that  so-called 
"chronic  cases"  present  the  distressing  scenes  of  great  excitement 
or  extreme  depression  and  agitation,  so  feared  by  some  for  their 
injurious  effect  upon  the  acute  cases.  It  is  rather  among  the 
acute  insane  themselves  that  such  scenes  occur,  and  hence  the 
necessity  of  acute  hospital  buildings  for  the  treatment  of  such 
conditions,  that  fine  classification  may  be  possible. 

There  are,  however,  chronic  cases  which  occasionally  suffer 
from  acute  exacerbations  which  require  the  same  treatment  as 

[89] 


similar  phases  of  disease  in  acute  cases,  and  only  when  such 
chronic  patients  are  cared  for  in  a  well-equipped,  large  hospital 
can  they  be  transferred  to  the  acute  hospital  department  and 
receive  proper  treatment. 

In  addition  to  all  the  above  we  now  know  that  infinite  possi- 
bilities exist  in  the  occupational  reeducation  of  even  the  most 
chronic  insane  patients.  But  not  only  do  the  county  institutions 
fail  to  provide  such  work,  as  such,  but  in  most  of  them  there  is  no 
knowledge  whatever  of  the  subject.  That  work  is  good  for  the 
chronic  insane  is,  of  course,  universally  conceded,  but  that  oc- 
cupation should  be  fitted  to  special  needs,  that  dormant  interests 
can  thus  be  awakened,  and  that  practically  new  mental  life  is 
often  the  result  of  intensive  personal  reeducational  effort  applied 
with  regard  to  individual  needs,  there  is  no  conception.  But 
such  is  the  fact  and  it  alone  would  seem  sufficient  to  render  forever 
obnoxious  the  idea  that  ordinary  custodial  care  is  good  enough 
for  the  chronic  insane,  however  less  the  cost. 


The  fact  that  county  institutions  do  not  and  cannot  supply 
the  demand  of  modern  psychiatric  progress  is  evident  from  a 
brief  consideration  of  their  organization.  Controlled  as  they  are 
by  Poor  Directors,  whose  thought  is  not  the  cure  of  insanity, 
many  even  expressing  an  open  incredulousness  as  to  its  possi- 
bility, such  institutions  are  conducted  in  conjunction  with 
almshouses  towards  whose  standard  they  inevitably  tend. 
Indeed,  as  has  been  noted,  in  some  instances  the  insane  and  the 
paupers  occupy  the  same  building,  and  in  but  few  instances  is 
there  any  appreciable  difference  in  the  character  of  the  care  given 
the  two  classes  of  individuals.  It  should  not,  however,  be  as- 
sumed that  the  faults  of  the  county  institutions  are  wilful  faults 
of  the  local  administrations ;  in  most  instances  the  local  stewards 
and  superintendents  of  county  institutions  were  found  to  be  men 
doing  their  duty  as  best  they  knew  and  as  best  they  could  under 
woefully  inadequate  conditions.  As  a  class,  they  were  found  to 
be  kindly,  humane  men,  who  in  the  vast  majority  of  instances 
appreciate  the  faults  of  the  existing  system  and  would  welcome 
State  care  of  the  insane. 

Aside  from  material  conditions,  the  most  universal  and  the 
most  serious  lack  is  the  want  of  medical  treatment  directed  to  the 

[90] 


cure  of  mental  disease,  as  such,  but  under  the  existing  organiza- 
tion of  county  institutions  such  lack  is  not  surprising.  The 
Poor  Directors  must  necessarily  be  chiefly  interested  in  the  matter 
of  expense;  should  the  poor  tax  be  raised,  their  chances  of  re- 
election are  of  course  jeopardized,  and  it  is  not  without  signifi- 
cance that  Institution  No.  35  is  the  only  county  institution  in  the 
State,  with  a  single  exception,  provided  with  continuous  baths  and 
other  modern  equipment  when  one  learns  that  it  alone  of  all 
the  county  institutions  is  governed  by  an  independent,  unsalaried 
Board  of  Trustees. 

It  is  contrary  to  ordinary  experience  to  expect  that  all  counties 
can  ever  be  induced  to  spend  sufficient  funds  to  properly  equip 
their  institutions.  In  fact,  it  would  appear  unjustified  to  expect 
it,  for  it  would  mean  a  prohibitive  per  capita  cost.  It  is  only  in 
large  institutions,  where  the  cost  is  distributed  over  a  large  num- 
ber of  patients,  that  the  expense  of  proper  equipment  assumes 
reasonable  per  capita  proportions,  and  when  adequate  facilities 
are  provided,  it  is  but  common  sense  to  expect  the  fullest  use 
to  be  made  of  them,  which  is,  of  course,  impossible  in  small 
institutions. 

It  has  been  argued  that  a  large  institution  is  undesirable, 
because  the  superintendent  is  unable  to  personally  know  and 
direct  the  treatment  of  individual  patients.  But  such  a  view 
of  the  matter  appears  superficial.  It  matters  little  to  the  patient 
who  the  individual  is  who  treats  him,  providing  that  individual 
be  competent  and  adequate  material  facilities  be  provided.  It 
would  appear  that  a  superintendent  fulfils  his  function  when  he 
sees  that  proper  facilities  and  treatment  are  provided,  retaining, 
of  course,  such  personal  supervision  as  is  possible.  It  is  more 
important  that  adequate  material  facilities  be  provided  to  sup- 
plement skilled  medical  treatment  than  that  the  latter  should  be 
administered  by  any  one  person;  the  above,  of  course,  implies 
a  well-organized  and  competent  staff,  as  none  could  successfully 
decry  the  importance  of  personal  treatment. 

To  remove  the  insane  from  almshouse  association,  with  all  that 
it  implies,  to  provide  proper  facilities  for  the  treatment  of  mental 
disease,  as  such,  including  chronic  as  well  as  acute  conditions,  to 
remove  the  whole  subject  of  the  care  of  the  insane  from  the  realm 
of  partisan  politics  and  at  the  same  time  accomplish  such  result 
at  a  minimum  expenditure  of  money  is  a  problem  which  appears 


in  no  way  possible  of  accomplishment  except  by  the  adoption  of 
State  care. 

As  a  necessary  corollary  there  should  be  a  State  Civil  Service 
for  officers  and  employees,  wherein  merit  alone  will  win  promotion 
and  where  like  salaries  will  be  paid  for  like  service  in  all  parts  of 
the  State — there  now  existing  great  inequality  in  this  regard. 
The  successful  operation  of  a  State  Care  system  likewise  implies 
a  central  coordinating  or  supervisory  bureau  or  commission 
empowered  to  maintain  proper  standards  and  to  recommend  the 
distribution  of  funds  where  the  greatest  needs  exist,  with  regard 
to  the  interest  of  the  State  as  a  whole,  all,  of  course,  under  proper 
checks.  In  such  connection,  the  budget  system  is  worthy  of 
consideration. 

Such  an  organization  should  not  displace  the  local  boards  of 
managers,  for  local  initiative  and  local  pride  should  be  stimulated 
in  every  proper  way  and  the  details  of  hospital  management 
should  be  left  to  them  and  the  superintendent.  So  it  would,  of 
course,  be  necessary  that  the  exact  balance  of  power  between  the 
central  and  local  authorities  be  very  carefully  worked  out. 

Such  a  definite  State-wide  scheme  is  as  much  in  the  interest 
of  true  economy  as  humanity,  for  only  thus  can  uniformity  of 
method  be  obtained,  with  resulting  economies  peculiar  to  large 
organizations.  The  present  lack  of  uniformity  in  both  business 
and  medical  methods  is  a  necessary  result  of  the  independent 
manner  in  which  each  institution  has  developed.  It  follows  that 
experience  gained  in  one  institution  has  been  lost  in  another, 
while  records  are  worthless  for  purpose  of  comparison.  By 
uniting  all  institutions  in  one  system,  the  experience  of  one  will 
become  the  property  of  all.  Records,  both  business  and  medical, 
being  prepared  alike  throughout  the  State,  will  be  thereby  en- 
hanced in  value.  And  thus  alone  can  medical  records  be  rendered 
available  for  scientific  study,  which  is  merely  the  formation  of 
conclusions  based  on  exact  data. 

There  are  numerous  matters  in  connection  with  the  care  of  the 
insane  in  Pennsylvania  which  merit  discussion,  but  which  can  but 
be  mentioned  within  the  limits  of  this  report.  Among  them  is 
the  need  for  codification  of  the  insanity  law,  with  the  elimination 
of  such  an  inconsistency  as  is  seen  in  the  provision  whereby  a  vol- 
untary patient  must  be  financially  able  to  provide  maintenance, 
when,  in  another  section,  the  law  reads  that  indigent  patients 

[92] 


shall  have  the  preference  in  securing  admission  to  hospitals  for  the 
insane.  It  is  by  the  treatment  of  voluntary  patients  that  later 
commitments  can  be  avoided,  as  the  importance  of  early  treat- 
ment cannot  be  overemphasized.  But  under  the  law  an  indigent 
patient  must  first  progress  in  his  mental  disease  until  commitable 
before  he  is  permitted  to  receive  treatment,  although  at  such 
point  he  is  given  preference. 

In  connection  with  the  need  of  early  treatment,  the  matter  of 
psychopathic  wards  in  general  hospitals  should  receive  attention. 
Despite  the  excellent  law  passed  at  the  last  session  of  the  As- 
sembly relative  to  such  wards,  but  two  have  been  established, 
and  the  practice  is  still  well-nigh  universal  of  placing  the  alleged 
insane  in  jails.  Indeed,  the  plans  of  a  jail  about  to  be  erected 
call  for  a  padded  cell  for  the  insane.  Insanity  being  a  matter  of 
public  health,  would  seem  to  more  properly  belong  to  the  realm  of 
health  officers  than  peace  officers,  or  even  poor  officials. 

A  uniform  method  of  commitment  should  be  provided.  As  at 
present  constituted,  the  law  appears  more  concerned  with  an 
alleged  insane  person's  right  of  freedom  than  right  of  treatment. 
Provide  all  legal  safeguards  thought  necessary  to  prevent  wrong- 
ful commitment,  but  do  not  make  them  mandatory,  except  on 
appeal.  If  a  person  knows  he  needs  treatment  and  desires  to 
receive  it,  make  the  way  easy.  There  is  far  more  danger  of  a 
mental  case  failing  to  receive  proper  treatment  than  there  is  of  a 
sane  person  being  committed  as  insane.  Experience  shows  the 
latter  but  rarely  happens,  and  it  is  safe  to  say  that  whenever  it 
has  happened  such  person  has  at  once  been  discharged. 

The  question  of  after-care  following  a  patient's  discharge  from 
the  hospital  and  the  subject  of  public  mental  hygiene  are  of  vast 
importance.  As  in  all  the  ills  to  which  human  flesh  is  heir  pro- 
phylaxis offers  more  hope  than  treatment  after  the  development 
of  disease.  The  statistics  prepared  by  the  National  Committee 
for  Mental  Hygiene  show  that  at  least  50  per  cent  of  the  insanity 
in  this  country  arises  from  preventable  causes — a  startling  fact, 
but  one  offering  encouragement  for  work  in  this  field.  It  is  in 
such  connection  that  there  should  be  closer  reciprocal  relations 
between  the  general  practitioner  and  the  mental  specialist. 

In  bringing  this  report  to  a  close,  it  is  unnecessary  to  make 
further  comments  on  the  conditions  found  to  exist  throughout 
the  State.  The  results  in  no  way  justify  the  existing  system  or 

l93l 


rather  lack  of  system.  A  remedy  is  demanded  and  it  is  hoped 
that  in  some  measure  this  report  has  pointed  the  way  to  com- 
plete State  care  as  the  remedy  needed. 

In  conclusion,  I  wish  to  express  to  the  members  of  your  com- 
mittee my  sincere  appreciation  of  the  many  courtesies  extended 
me,  and  to  your  Executive  Secretary,  Mr.  Robert  D.  Dripps,  my 
gratitude  for  his  ever-ready  assistance  and  kindly  encouragement. 

Respectfully  submitted, 
(Signed)     C.  FLOYD  HAVILAND. 


94 


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